New Patient Form

"*" indicates required fields

Please fill out your registration and health history information online! This form has been designed for both children and adults. After completing this confidential questionnaire, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. We will have your information when you arrive for your evaluation appointment. If you wish us to complete a complimentary insurance benefits check, please complete the insurance portion of the form.

First Name*

Middle Name

Last Name*

Title (Mr. Mrs. Ms. Miss. Dr. Other)*

I prefer to be called (Nickname)

Address*

Street Address City State Zip

Cell/Mobile Phone*

Email*

Date of Birth*

Gender*

School (if patient is a minor)

Parent's or guardian's names (if patient is a minor)

Whom may we thank for referring you to our office?

Other family members seen by us

Responsible Party Information (For minors)

Custodial Parent(s) Full Name and Title (Mr. Mrs. Ms. Miss. Dr. Other)

Patient lives with

Who is financially responsible for this account?

Who will be responsible for bringing patient to orthodontic appointments?

Parent 1's Full Name and Title

Cell/Other Phone

Mailing Address (if different)

Street Address City State Zip

Occupation

Employer

Birth Date

Parent 2's Full Name and Title

Cell/Other Phone

Mailing Address (if different)

Street Address City State Zip

Occupation

Employer

Birth Date

Emergency Information

Name of Emergency Contact (if different from above)

Phone

Dentist

Patient's Dentist*

City

State

Date Last Seen

Reason

Other dentists/dental specialists being seen

Any dental work that needs to be completed?

General Information

What concerns you about your/your child's teeth?

How do you/does your child feel about orthodontic treatment?

Who suggested that you/your child might need orthodontic treatment?

Why did you select our office?

Describe any previous orthodontic treatment or consultations

What are your/your child's hobbies/activities/sports?

Do you/does your child play any musical instruments?

How much importance do you place on the health of your teeth?

How often do you/does your child brush?

How often do you/does your child floss?

Dental Insurance Information

We offer a complimentary dental insurance benefits check. If you check YES to the first question below, please fill out the rest of this section COMPLETELY with your dental insurance information for us to verify your benefits ahead of time. If NO, please fill out "n/a" on the fields below.

Do you have dental insurance you wish us to check?*

Yes

Primary Policy Holder's Full Name*

Primary Policy Holder Birthdate*

Policy Holder's Social Security Number (U.S. only)*

Name of Insurance Company (i.e. Metlife, Guardian, etc.)*

Policy Group Number*

Policy Individual ID Number*

Insurance Company Claims Address*

Street Address City State

Insurance Company Phone Number*

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues as they may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician

Date of Last Visit

MEDICAL HISTORY: Check all that apply.

Is the patient allergic to any medication?

Yes

Is the patient taking any medications? Please list and describe:

Yes

Does the patient have a history of any major illness?

Yes

Has the patient had any major operations?

Yes

Has the patient ever been involved in a serious accident?

Yes

Is the patient pregnant?

Yes

Does the patient use tobacco?

Yes

Now or in the past, has the patient ever had

ADD

ADHD

Anemia

Angina, arteriosclerosis, stroke, or heart attack

Arthritis or joint problems

Asthma, sinus problems, hayfever

Autism spectrum

Birth defects or hereditary problems

Bone fractures, or major head injuries

Cancer, tumor, radiation treatment or chemotherapy

Chest pain, shortness of breath, tire easily, swollen ankles

Congenital Heart Defect

Diabetes or low sugar

Do you/does your child eat a well balanced diet?

Does the patient frequently breathe through the mouth?

Does the patient require antibiotic prophylaxis before dental appointments?

Endocrine or thyroid problems

Excessive bleeding or bruising

Frequent ear infections, colds, throat infection

Frequent headache or migraines

Immune system problems

Has the patient ever taken intravenous bisphosphenates such as Zometa, Aredia, or Didronel for bone disorders?

High or low blood pressure

History of eating disorder (anorexia, bulimia)

History of osteoporosis

Hepatitis, jaundice, or other liver problems

Kidney problems

Mental health disturbance or depression

Seizures, fainting spells, neurologic problems

Sensory condition

Skin disorder (other than common acne)

Tonsil or adenoid condition/removed

Vision, hearing, or speech problems

Has the patient ever had allergies or reactions to any of the following?

Acrylics

Animals

Aspirin

Foods

Ibuprofen (Motrin, Advil)

Latex (gloves, balloons)

Local anesthetics (novocaine, lidocaine, etc)

Metals (jewelry, clothing snaps)

Penicillin

Other antibiotics

Plant pollens

Other substances

DENTAL HISTORY: Now or in the past, has the patient ever had

Erupting teeth very early or very late

Primary (baby) teeth removed that were not loose

Permanent or extra (supernumerary) teeth removed

Supernumerary (extra) or congenitally missing teeth

Chipped or injured primary or permanent teeth

Any sensitive or sore teeth

Jaw fractures, cysts, infections

Any teeth treated with root canals or pulpotomies

Frequent canker sores or cold sores

History of speech problems

Frequent oral habits (sucking thumb/fingers, chewing pens, etc)

Teeth causing irritation to lip, cheek, or gums

Tooth grinding or clenching

Clicking, locking in jaw joints

Soreness in jaw muscles or face muscles

Treatment for "TMJ" or "TMD" problems

Broken or missing fillings

Any serious trouble associated with previous dental treatment

Diagnosis of gum or periodontal disease

Difficulty breathing through nose

Mouth breathing habit or snoring at night

Diagnosis of obstructive sleep apnea

Are there any medical conditions we have not discussed of which we should be aware?

Please describe any significant family medical history

Signature

Name of person completing this form*

Relationship to patient*

Electronic signature -- please enter your full name*

Today's Date*

MM slash DD slash YYYY

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.*

I have read the above questions and understand them. I will not hold Graber & Gyllenhaal Orthodontics or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I will notify Graber & Gyllenhaal Orthodontics of any changes in my/my child's medical or dental health.

Patient Photo Release

hereby authorize Graber & Gyllenhaal Orthodontics or any of their assignees to take photographs/video images of my teeth, jaws, and face. I understand that the photographs/video images will be used as a record of my care and may be used for communication with other healthcare professionals, educational publications (orthodontic journals), and education lectures. The content may also be used for marketing or advertising purposes (including website publication, social media posts, etc.). I further understand that if the photographs, videos, and/or testimony are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs, slides or videos. If I wish to revoke this consent, I may do so in writing.

Please check one option*

I consent to my photographs, videos, and/or testimony being used in any of the above stated situations

I only agree to have my teeth shown without any identifying features

I do not give consent for any use of photographs, testimony, videos, or my likeness

Patient Name*

Date*

Parent/Legal Guardian (if patient is a minor)

Signature*

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out: -Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); -Obtaining payment from third-party payers (e.g. my insurance company); -The day-to-day healthcare operations of your practice I have been informed of, and given the right to review and secure a copy of your Notices of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you to obtain the most current copy of this notice. I understand that I have the right to request restriction on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Patient Name*

Date*

Signature of Patient or Parent/Legal Guardian (if patient is a minor)*