New Patient Form

1 PATIENT INFORMATION

2 RESPONSIBLE PARTY INFORMATION

3 INSURANCE INFORMATION

4 MEDICAL HISTORY

5 DENTAL HISTORY

PATIENT INFORMATION
Date*
Date Format: MM slash DD slash YYYY
Patient's Name*
First Middle Last
Patient's Street Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
Birth Date*
Date Format: MM slash DD slash YYYY
Social Security Number
If Patient is a Minor, give Parent’s or Guardian’s Full Name
First Last
Brothers and/or Sisters (names & ages)
Whom may we thank for referring you to our office?*
Who is your General Dentist?*

RESPONSIBLE PARTY INFORMATION
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Years at this address?*
Home Phone
Work Phone
Cell Phone
Previous address (if less than 3 years)
Street Address Address Line 2 City State ZIP Code
Marital Status*
Social Security Number
Birth Date*
Date Format: MM slash DD slash YYYY
Relationship with Patient*
Employer*
Occupation*
Number of Years at this Employer*
Spouse's Name
First Middle Last
Spouse’s Employer
Spouse's Occupation*
Number of Years at this Employer*
Spouse's Social Security Number
Spouse's Birth Date
Date Format: MM slash DD slash YYYY
Spouse's Work/Cell Phone

INSURANCE INFORMATION
Insured’s Name*
First Last
Subscriber ID*
Insured’s Address*
Street Address Address Line 2 City State ZIP Code
Insurance Company*
Group Number*
Local Number*
Insurance Address
Street Address Address Line 2 City State ZIP Code
Dual Coverage*
If yes, full name of covered person
First Last
Social Security Number
Birth Date*
Date Format: MM slash DD slash YYYY
Work/Cell Phone*
Electronic Consent*
I agree to the terms.
As a courtesy to our patients we file your insurance claim forms. We will attempt to obtain as much insurance coverage for you as possible. However, please understand that you are responsible, in full, for all charges rendered. Any insurance estimates provided by this office should be considered a guideline only. When final insurance payment is received, your account will be reconciled. I authorize the release of any information necessary to process my insurance claims and, also herby authorize payment of insurance benefits to Paige Orthodontics.
Electronic Signature*
First Last
Date Signed*
Date Format: MM slash DD slash YYYY

DENTAL HISTORY
Has the patient ever received a severe blow to the teeth or jaws?*
If so, where?
Has the patient been to a dentist in the last 12 months?*
Does the patient constantly have sore or bleeding gums?*
Have any of the patient’s teeth been removed?*
Which?
- Baby teeth
- Permanent
Has the patient ever sucked fingers, thumb, lips, or tongue?*
Is the patient still or at what age did it stop?
Does the patient play a wind instrument?*
If so, what kind:
Who first noticed the need for orthodontic treatment?*
Has another member of the family had orthodontic treatment?*
Has the patient ever had “braces” before?*
Does any member of the family or close relatives have a similar arrangement of teeth or similar appearance of jaw?*
If so, who?
Is the patient interested in: (please check all apply)*
- Appearance
- Better speech
- On advice of friends
- On advice of dentist
- TMJ
- Other
Is the patient dissatisfied with the appearance of their teeth?*
If so, please describe what the patient would like to have fixed:
If you are filling out for a minor, are you concerned about the appearance of their teeth? If so, please describe what you would like to have fixed:
Is the patient dissatisfied with the appearance of their facial features (nose, chin, jaw, ect.)?*
If so, what in particular:
Has the patient ever been teased about the appearance of their teeth or face?*
Please take this space to give us any comments or information you feel may be pertinent to the patient’s situation regarding corrective dental procedures:
NOTE: We make every attempt to schedule appointments for convenience, but orthodontics appointments may infringe on your school/ work schedule.
Please type your initials indicating that you understand about appointment scheduling:*
I understand that records are stored electronically and that an electronic copy shall be considered an original for all purposes.
Electronic Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION.

By law, we are required to provide you with our Notice of Practice. Please sign below acknowledging your receipt of this information. This shall also serve as consent to use and/or disclose your protected health information to carry out treatment, payment activities, and health care operations. If you should have any questions regarding this Notice and consent, you may contact: Paige Orthodontics at 281-358-6580
Patient, parents or legal Representative (electronic signature):*
First Last
Date*
Date Format: MM slash DD slash YYYY

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

DENTAL HISTORY

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION.