New Patient Intake Form (Bundle) - Smilebilss - Arango Ortho

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New Patient Intake Form

Reviewed by Doctor:

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Month

Day

Year

Hour

Minute

AM/PM

The following information is for a(n):*

Adult Child

Gender:*

Male Female Other

Patient's First Name:*

Patient's Last Name:*

Patient's Date of Birth*

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Month

Day

Year

Primary Phone Type:

Phone:

Address

City

State

Zip Code

Email Address:

SSN#:

Who is your Dentist?

Dentist Phone Number:

Responsible Party Information

Responsible Party Full Name:

Phone Number:

Mailing Address(if different from patient):

Address Line 1

Address Line 2

City

State

ZIP Code

Email (if different from patient):

How would you prefer to be contacted?

Phone Call Text Email

Relationship to patient:

SSN:

Would you like to get braces today?

Yes No

How did you hear about us?

Dental Insurance

Do you have dental Insurance?

Yes No

Insured’s Name:

Date of Birth:

SSN/Member ID:

Employer Name:

Insurance Company:

Group Number:

Policy Number:

Effective Date:

Relationship to Subscriber:

Phone Number:

Insurance Company Address:

Do you have Secondary Insurance?

Yes No

Secondary Insured’s Name:

Secondary Date of Birth:

Secondary SSN/Member ID:

Secondary Employer Name:

Secondary Insurance Company:*

Secondary Group No:

Secondary Policy Number:

Secondary Effective Date:

Relationship to Subscriber*

Secondary Phone Number:*

Secondary Insurance Company Address:*

Emergency Contact

Contact in case of Emergency (Name):

Relationship to patient

Emergency Email:

Emergency Phone:

Dental/Medical History

Patient Dentist Name:

Date of Last Visit:

Have you seen a dentist in the last six months?

Yes No

Do you have cavities, gum problems, or other dental concerns that need treatment?

Yes No

If so, please explain:

Have you had any injuries to the teeth, jaws, or head?

Yes No

Please explain:

Do you have a Primary Care Doctor ?

Yes No

Doctor’s Name

Doctor’s Phone Number:

Do you have any medical or other health conditions that you are currently being treated for?

Yes No

Please explain medical /health conditions

Do you have any history of bleeding problems?

Yes No

Please explain bleeding problems

Do you take any prescription or over-the-counter medications?

Yes No

List medications

Do you have any allergies to medication, food, or environmental substances such as latex?

Yes No

List allergies

Are you pregnant or is there a chance you are pregnant?

Yes No

Photo Release Form

I consent to the use of my image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Smilebliss^TM or (Provider) for any lawful use Provider deems appropriate, including for treatment, advertising his/her/its services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any rights to my likeness or any image of me obtained by any photographic or digital means by Smilebliss^TM or Provider during my treatment. I understand that I am entitled to no consideration, remuneration, or payment for the use of my image in any advertising, promotional or educational materials.

I understand any image or likeness of me may be altered before use if deemed appropriate by Smilebliss^TM or Provider. I agree that I have no right to be consulted about or approve of any such alterations before my image is used.

I understand that Smilebliss^TM or Provider will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that Smilebliss^TM or Provider cannot guarantee my complete privacy if third parties use my image or likeness.

I understand and agree that Smilebliss^TM or Provider may use information regarding my health condition, including information regarding my diagnosis, course of treatment, date of birth and age, and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image of me. I understand that Smilebliss^TM or Provider may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and likeness.

I have read the preceding in its entirety and understand its terms.*

Agree

Notice of Privacy Policies

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review carefully. The Privacy of your health information is important to us.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4 / 1 / 03 , and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use or disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use or disclose your health information in connection with our healthcare operations.

Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

To Your Family, Friends and Persons Involved in Care: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare. We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health Activities: We may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.
Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.
Court Orders and Subpoenas: We may disclose information in response to an appropriate court order or subpoena.
Law Enforcement: Subject to certain restrictions, we may disclose information required by law enforcement.
Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Workers Compensation: We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illness.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters). We may also contact you to provide information about treatment alternatives or other health-related information that may be of interest to you.

Patient Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services.

I have reviewed a copy of this office’s Notice of Privacy Practices and understand I will receive a copy via email.*

Agree

Informed Consent

Click here to read the Informed Consent Policy

I have read the above link and understand all of the information*

Agree

ACKNOWLEDGEMENT I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the undersigned dentist and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the dentist indicated below to provide the treatment. I also authorize the dentist to provide my health care information to my other health care providers. I understand that my treatment fee covers only the orthodontic part of the treatment, and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment. *

Agree

CONSENT TO UNDERGO ORTHODONTIC TREATMENT I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment, and to the above doctor(s) and, where appropriate, staff providing orthodontic treatment prescribed by the above doctor(s) for the above individual. I fully understand all of the risks associated with the treatment.*

Agree

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION I hereby authorize the above doctor(s) to provide other health care providers with information regarding the above individual's orthodontic care as deemed appropriate. I understand that once released, the above doctor(s) and staff has(have) no responsibility for any further release by the individual receiving this information.*

Agree

CONSENT TO USE OF RECORDS I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education, or publication in professional journals.*

Agree

• GOOD BRUSHING AND FLOSSING IS ESSENTIAL FOR SUCCESSFUL ORTHODONTIC RESULTS.

• MUST GO TO DENTIST EVERY 6 MONTHS FOR DENTAL CLEANING.

• IF BRUSHING BECOMES POOR WE WILL REMOVE BRACES, END TREATMENT, AND YOU MAY STILL BE FINANCIALLY OBLIGATED.

Additional Comments:

CONSENT FOR USE OF

Health Information

Patient Giving Consent

To The Patient

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry outtreatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I give my consent*

I give my consent I do not give my consent

I certify this information is true and correct to the best of my knowledge. I understand that I am responsible for all financial charges.*

Agree

Patient/Parent's Signature*

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