"*" indicates required fields Welcome! We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health. Patient Name:* First Last SS# (21 & up) Sex (Circle One)* Female Male Age* Birth Date* MM slash DD slash YYYY Address* City* State* Zip* Cell Phone*Alternate Phone (Work / Cell)E-Mail* Marital Status* Single Married Widowed Separated Divorced Whom may we thank for referring you?* Notify in case of emergency:* Emergency contact #* Person responsible for account:* Relation to patient:* Responsible party birth date: MM slash DD slash YYYY SS# Phone#Address (if different from patient) Responsible party employed by: Occupation What concerns do you have about your smile? DENTAL HISTORYCheck if you have/had any of the following: Bad Breath Food collecting between teeth Periodontal treatment Prior dental trauma Bleeding Gums Grinding or clenching teeth Sensitivity to cold/hot Finger /Tongue Habit Clicking or popping jaw Loose teeth or broken fillings Sensitivity when biting Prior Orthodont How often do you brush? Floss? How do you feel about the appearance of your smile? Have you ever experienced any adverse reactions during or in conjunction with a medical procedure? Yes No If yes, please explain:MEDICAL HISTORYAre you currently under the care of a physician? Yes No Physician’s Name PhoneHave you ever had a blood transfusion? Yes No Have you ever taken Fen-Phen/Redux? Yes No Are you pregnant? Yes No Nursing? Yes No Taking birth control? Yes No Check if you have had any of the following: AIDS/HIV Positive Circulatory Problems Hemophilia/abnormal bleeding Pacemaker/Heart Surgery Surgical Implant Anaphylaxis Cortisone Treatment Herpes Psychiatric Care Swelling of feet or ankles Arthritis/Rheumatism Cough, persistent Hepatitis Rheumatic/Scarlet fever Venereal Disease Artificial heart valve Coughing up blood High Blood Pressure Shingles Artificial Joints Diabetes Jaw pain Shortness of breath Asthma Epilepsy Kidney disease/malfunction Skin Rash Atopic (allergy prone) Fainting Liver disease Spina Bifida Autism Food Allergies Material Allergies (LATEX, wool, metal) Stroke Back problems Glaucoma Mitral valve prolapsed Thyroid disease or malfunction Blood disease Headaches Nervous problems Tobacco Habit Cancer Heart Murmur Rapid weight loss/gain Tonsillitis Chemical dependency Radiation treatment Tuberculo Heart Problems Other Please describe Heart Problems Please describe Other Problems Is patient currently taking any medications? If yes, list all Does Patient have drug allergies? If yes, list all INSURANCE INFORMATIONPolicy holder name* DOB* MM slash DD slash YYYY Insurance name* Member ID* Group#* Employer* Cusomer Svc Phone* Dentist Last visit MM slash DD slash YYYY Authorization: I have reviewed the information on the questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the Orthodontist to help determine appropriate and healthful orthodontic treatment. If there is any change in my medical status, I will inform the Orthodontist. I authorize the insurance company indicated on the form to pay Windermere Orthodontics & all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.Signature HiddenDate MM slash DD slash YYYY Patient Acknowledgement of Receipt of Notice of Privacy PracticeI have received a copy of this office’s NOTICE OF PRIVACY PRACTICES. It provides information about how the office may use and disclose your Protected Health Information (PHI).I have been provided the opportunity to review the Notice of Privacy Practices.Patient Name Patient Signature (or parent) HiddenDate MM slash DD slash YYYY Notice of Privacy Practice This notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review it 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 the 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 April 1, 2003 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 on 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 anytime. For more information about our privacy practices or for additional copies of this notice please contact us using the information listed above.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, dentist or other healthcare provider providing treatment to you.Payment: We may use and disclose your health information to obtain payment for services we provide to you.Healthcare Operations: We may use and disclose 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’s performance conducting training programs, accreditation, 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 information or to disclose it to anyone for any purpose. If you give us an authorization you may revoke it in writing at anytime. Your revocation will not affect any use or disclosures permitted by your authorization, while it was in effect, unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in the notice.To Your Family and Friends: 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 of your healthcare, but only if you agree that we may do so.Persons Involved In Care: 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 or your location, your general condition or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, and medical supplies, x-rays, or other similar forms of health information.Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.Required by Law: We may use or disclose your health information when we are required by law to do so.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, or 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.