New Patient Form

New Patient Information

Date

Patient's First Name

Patient's Last Name

Patient's Middle Initial

Prefers to be called

Birth Date

Age

School

Grade

Gender at birth

Male

Female

With what gender do you identify?

Height

Weight(lbs)

How did you hear about us?

What are your hobbies?

In your own words, describe the patient's main orthodontic concern:

Please rank in order of importance your priority in choosing an orthodontic office. Please use each number only once (1 being the most important and 3 being least important).

Optimal orthodontic care and service:

1

2

3

Convenience / location of office:

1

2

3

Lowest cost for orthodontic care:

1

2

3

Address

City

State

Zip Code

How long at this address?

Home Phone

Cell Phone

Email

Employer

Occupation

How long at current employer?

Business Address

City

State

Zip Code

Work Phone

In case of emergency, contact:

Name

Phone

Relationship to patient

Is the patient a minor?

No

Yes

Who is financially responsible for the account?

First Name

Last Name

Address

Phone Number

Email

Parent 1/Guardian 1 Information

First Name

Last Name

Home Phone

Cell Phone

Email

Birth Date

Address

City

State

Zip Code

Employer

Occupation

How long at current employer?

Business Address

City

State

Zip Code

Work Phone

Parent 2/Guardian 2 Information

First Name

Last Name

Home Phone

Cell Phone

Email

Birth Date

Address

City

State

Zip Code

Employer

Occupation

How long at current employer?

Business Address

City

State

Zip Code

Work Phone

Patient lives with:

Parent 1/Guardian 1

Parent 2/Guardian 2

Other

Other:

Who will be responsible for bringing the patient to their orthodontic appointments?

Name

Relationship to Patient

Name

Relationship to Patient

Name

Relationship to Patient

Orthodontic Insurance Information

If you have orthodontic coverage, the following information is required for submitting an insurance claim. Please complete the entire section to ensure proper billing. Thank you.

Insured's Name

Insured's Birth Date

Insurance Company

Group Number

Policy ID/Social Security #

Insurance Company Address

Phone Number

Does this policy have orthodontic benefits?

No

Yes

Don't Know

Does the patient have dual coverage? if yes, please complete the following insurance info:

No

Yes

Insured's Name

Insured's Birth Date

Insurance Company

Group Number

Policy ID/Social Security #

Insurance Company Address

Phone Number

Financial Responsibility

Who is financially responsible for this account?

Address

City

State

Zip Code

Cell Phone

Home Phone

Email

Who will be responsible for bringing the patient to their orthodontic appointments?

Relationship to patient

General Information

Number of children in the family:

Name of any family member in treatment or previously with us:

Name of previous orthodontist

General dentist's name

Address

Phone

Date of last dental check-up

Is the patient currently having dental work completed?

Yes

No

If yes, please describe:

Medical physician's name

Address

Phone

Date of last medical check-up

Is the patient currently under medical treatment?

Yes

No

If yes, please describe:

Medical Information

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

Is, Has or Does the patient...

allergic to latex?

Yes

No

take antibiotic premedication prior to any dental procedures?

Yes

No

If yes, please list medication type and dosage:

in general good health at this time?

Yes

No

If no, please specify:

had any adverse response to any drugs, including penicillin?

Yes

No

If yes, please specify:

allergic to any known materials resulting in hives, asthma, eczema, etc.?

Yes

No

If yes, please specify:

List all medications/supplements you are currently taking and dosages.

ever had any major operations including hip/joint replacement?

Yes

No

If yes, please specify:

have any wounds healed slowly or presented other complications?

Yes

No

If yes, please specify:

ever had any radiation therapy or chemotherapy?

Yes

No

If yes, please specify:

ever had a serious accident involving facial and/or head injuries?

Yes

No

If yes, please describe:

Does the patient have or has he/she ever had:

ARTHRITIS OR PAINFUL JOINTS

Yes

No

EMOTIONAL PROBLEMS

Yes

No

INFECTIOUS DISEASE

Yes

No

CARDIOVASCULAR DISEASE

Yes

No

HEARING DISORDER

Yes

No

SINUS PROBLEMS

Yes

No

Other

Yes

No

Other pertinent conditions not listed:

Does the patient snore?

Yes

No

Does the patient have unexplained awakenings from sleep?

Yes

No

Does the patient, or has the patient been told that you stop breathing for short periods during sleep?

Yes

No

Does the patient get excessively tired during the day and/or fall asleep when you should be awake?

Yes

No

Is the patient on a diet at this time?

Yes

No

Is the patient pregnant?

Yes

No

Has the patient ever smoked or used tobacco products?

Yes

No

If so, how long ago?

Dental History

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. To thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

When was the patient's last full-mouth x-rays taken?

Where?

Does the patient's gums bleed?

Yes

No

Has the patient ever had gum disease, or periodontal treatment?

Yes

No

If yes, please specify:

Does the patient frequently get sore spots in their mouth?

Yes

No

Does the patient have any dental complaints at the present time?

Yes

No

If yes, please describe:

Does the patient experience frequent headaches?

Yes

No

Does the patient have a history of back or neck injuries? whiplash?

Yes

No

If yes, please specify:

Does the patient have any clicking or popping of their jaw (tmj)?

Yes

No

Does the patient have pain in or around their ears?

Yes

No

Does any part of the patient's mouth hurt when clenched?

Yes

No

Does the patient habitually clench or grind their teeth during the night or day?

Yes

No

Does the patient have any history of lip sucking or biting?

Yes

No

Does the patient have any history of nail biting?

Yes

No

Does the patient have any history of thumb or finger sucking?

Yes

No

If yes, until what age?

Does the patient have any history of tongue thrusting?

Yes

No

Does the patient have any history of speech difficulty or speech therapy?

Yes

No

Is the patient a mouth breather?

Yes

No

Does the patient chew on only one side of their mouth?

Yes

No

If so, why?

Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc )?

Yes

No

If so, where?

Has the patient ever taken any appetite suppressants (fen-phen, dexfenfluramine, fenfluramine or other)?

Yes

No

Has the patient ever taken medication for treatment of osteoporosis?

Yes

No

If yes, indicate medicated dosage

Has the patient ever had any poor dental experiences in the past?

Yes

No

If yes, explain:

Supplemental Informed Consent

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus," at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Patient's First Name

Patient's Last Name

Although exposure is unlikely, do you accept the risk and consent to treatment?

Yes

No

Signature of Parent/Guardian

Date

Relationship to Patient

Release and Waiver (HIPAA)

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to my child during the period of such orthodontic care to third party payers and/ or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services, and I am responsible for any benefit not paid by insurance or difference in cost due to lapse in coverage. I agree to be responsible for payment of all services rendered on my child's behalf. I understand that providing incorrect information can be dangerous to my child's health. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child's medical or dental health. I understand that the initial exam with Dr. Zuch is of no charge, and any succeeding services such as pretreatment diagnostics are rendered at additional cost. I have read/reviewed The Tooth Mover's complete HIPAA policy at http://www.mytoothmover.com.

By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.

Signature of Parent/Guardian

Date