SymplSign

Patient Information

Patient's Name^*

Age

Birth date^*

Name you like to be called

School^*

Grade^*

Address^*

City^*

State^*

Zip^*

Home Phone #

Cell Phone #^*

Social Security #

Email^*

Whom may we thank for referring you to our office?^*

Parent/Legal Guardian Information

*Name^*

Home Phone#

Cell Phone #^*

Address

City

State

Zip

Marital Status^*

Relationship to patient^*

Social Security #

Birth date^*

Email^*

Employer

Occupation

*Name

Home Phone #

Cell Phone #

Address

City

State

Zip

Marital Status

Relationship to patient

Social Security #

Birth date

Employer

Occupation

Dental Insurance Information – Please Provide All Information In Order To accurately verify benefits

Insured Name

Insured's SS#

Insured's DOB

Insurance member ID

Group #

Insurance Co

Insurance Co. Address

Phone

Insured's Employer

Do you have dual coverage?

If yes: Insured Name

Insured SS#

Insured member ID

Group

Insurance Co

Insured's Employer

Insurance Co. Address

Medical/Dental History

Physician's Name^*

Phone

Dentists Name^*

Phone

Is the patient currently under any medical treatment?

If So What Kind?

Does the patient have pain, clicking, and/or popping noises in the jaw?

Is the patient aware of either clenching or grinding of teeth?

History of Night Guard?

Does the patient have frequent headaches?

How often?

Does the patient have ear problems? (Aches, ringing, dizziness, fullness)

Does the patient have difficulty breathing through the nose?

Does the patient have habits such as nail biting, finger or thumb sucking, lip or cheek biting?

Does the patient have speech problems, or are you in speech therapy?

Has the patient had your tonsils and/or adenoids removed?

Has there been any history of:

Joint swelling

Asthma

Aids

HIV

Kidney

Other major illnesses

Does the patient bleed easily?

Liver Condition

Epilepsy

Rheumatic fever

Anemic

Does the patient have a tendency to faint or become dizzy?

Does the patient have allergies?

(LATEX, Sulphur, penicillin, novocaine, etc.)

Is the patient currently taking any medication?

List

Has there been a history of growth hormone therapy?

If so when and how long?

Does the patient have a heart condition?

Do you pre-medicate?

Cardiologist

Is the patient currently pregnant?

If yes, what is the due date?

Date of first menstrual cycle

Has the patient been diagnosed with sleep apnea?

If so do you use CPAP machine?

Does the patient smoke or chew tobacco?

Quantify Usage

History of facial trauma or injuries to the teeth?

Explain

Has the patient had any permanent teeth, other than wisdom teeth, extracted?

Have we treated any other family members?

Who

Any other medical concerns not listed above

Privacy Notice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers and demographic data) may be used or disclosed by us in one or more of the following respects:

To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
To third party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.)
To certifying, licensing and accrediting bodies (i.e., The American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
Internally, to all staff members who have any role in your treatment;
To other patients and third parties who may see or overhear incidental disclosures about your treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke:

Under the new privacy rules, you have the right to:

Request restrictions on the use and disclosure of your protected health information;
Requested confidential communication of your protected health information;
Inspect and obtain copies of your protected health information through asking us;
Amend or modify your protected health information in certain circumstances;
Receive an accounting of certain disclosures made by us of your protected health information; and,
You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation)

We have the following duties under the privacy rules:

By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
To abide by the terms of our Privacy Notice that is currently in effect;
To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by use, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:

Honor any request by you to restrict the use or disclosure of your protected health information;
Amend your protected health information if, for example, it is inaccurate and incomplete: or;
Provide an atmosphere that is free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to the persons at our office. Thank you.

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Patient Information

Parent/Legal Guardian Information

Dental Insurance Information – Please Provide All Information In Order To accurately verify benefits

Medical/Dental History