Child HHF | Huntersville Smiles Step 1 of 11 9% New Patient Form - ChildWe would like to welcome you to our orthodontic family. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible! Thanks for your cooperation!Patients’ Name * Required First Middle Initial Last Preferred Email * Required Preferred Cell Phone * RequiredPreferred method of communication * Required Home Phone Cell Phone Text / SMS Email Patient InformationNickname Gender * Required Male Female Home Address * Required Street Address City Zip Code School Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenAgeSibling Name/Birthdate Sibling Name/Birthdate Sibling Name/Birthdate Sibling Name/Birthdate Please list any other family members seen in our office Who may we thank for referring you to our office? * Required Parent/Guardian InformationRelationship to Patient * Required Mother Step-Mother Father Step-Father Guardian Parent/Guardian Name * Required First Last Cell Phone * RequiredHome PhoneWork PhoneEmployer Employer Address Street Address City Zip Code Is there an additional parent or guardian that needs to be added? * Required Yes No Additional Parent/Guardian InformationRelationship to Patient Mother Step-Mother Father Step-Father Guardian Parent/Guardian Name First Last Cell PhoneHome PhoneWork PhoneEmployer Employer Address Street Address City Zip Code Responsible Party InformationResponsible Party Name * Required First Last Social Security No. * Required Home Phone * RequiredWork PhoneResponsible Party Address * Required Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Dental InsuranceDo you have dental insurance? * Required Yes No Dental Insurance InformationSubscriber Name Relationship to Patient Subscriber BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's Employer Insurance Company Name Insurance PhoneGroup Number ID Number Insurance Company Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Do you have secondary dental insurance? * Required Yes No Secondary Dental Insurance InformationIf you have additional dental insurance you would like us to be aware of, please include that here. Otherwise, you can skip this section, and continue with your application.Subscriber Name Relationship to Patient Subscriber BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's Employer Insurance Company Name Insurance PhoneGroup Number ID Number Insurance Company Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Patient Dental HistoryAre you under the care of a dentist? * Required Yes No Patient's Dentist Dentist's City Dentist's PhoneDate of last dental cleaning? * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What are the main concerns that you would like orthodontics to accomplish? * RequiredHas there been previous orthodontic treatment? * Required Yes No If yes, by whom? What aspect of orthodontic treatment are you most concerned about? * Required Quality Cost Discomfort Length of Treatment Is the patient frightened or anxious about orthodontic treatment? * Required Yes No Is the patient concerned about the appearance of their teeth? * Required Yes No Have there been primary (baby) teeth removed by a dentist? * Required Yes No Is there or has there been a concern about periodontal (gum and bone) problems? * Required Yes No Is there any UNUSUAL Dental History? * Required Yes No If there is unusual dental history, please explain: Have any teeth been bumped or injured? * Required Yes No If yes, please explain: Does the patient have a tendency to gag easily? * Required Yes No Do any speech problems exist? * Required Yes No Has the patient had any serious issues associated with any previous dental treatment? * Required Yes No Has the patient ever HAD or PRESENTLY HAVE any of the following habits?Thumb sucking * Required Yes No Lip biting * Required Yes No Grinding or clenching teeth * Required Yes No Finger sucking * Required Yes No Nail biting * Required Yes No Snoring * Required Yes No Tongue thrusting * Required Yes No Mouth breathing * Required Yes No Smoking/Tobacco Chewing * Required Yes No Any other habits? Patient Medical HistoryIs the patient under the care of a physician at this time? * Required Yes No Physician's City Patient's Physician Physician's PhoneWhy is the patient seeing a physician? Is the patient currently pregnant? * Required Yes No Has the patient ever HAD or PRESENTLY HAVE any of the following?Heart Trouble * Required Yes No Heart Murmur * Required Yes No Artificial Heart Valve/Pacemaker * Required Yes No Mitral Valve Prolapse * Required Yes No High/Low Blood Pressure * Required Yes No Rheumatic Fever * Required Yes No Diabetes * Required Yes No Arthritis * Required Yes No Tumors * Required Yes No Convulsions * Required Yes No Epilepsy * Required Yes No Cancer * Required Yes No Sleep Disorders * Required Yes No Hepatitis * Required Yes No Tuberculosis * Required Yes No HIV / AIDS * Required Yes No Bleeding Disorders * Required Yes No Glaucoma * Required Yes No Glandular Disorders * Required Yes No Genetic Disorders * Required Yes No Kidney Disorders * Required Yes No Breathing Disorders * Required Yes No Fainting | Dizziness * Required Yes No Mental Health or Behavioral Problems * Required Yes No Headaches * Required Yes No Cleft Lip or Palate * Required Yes No Jaw Clicking/Popping * Required Yes No Jaw Stiffness/Locking * Required Yes No Jaw Soreness * Required Yes No Deep Gum Cleaning * Required Yes No Treated for TMD or TMJ * Required Yes No Osteoporosis * Required Yes No Jaw Pain * Required Yes No Ringing in Ears * Required Yes No Other * Required Yes No If you answered other, please list those below: Is the patient's general health good at this time? * Required Yes No Is the patient taking any medication(s) at this time? * Required Yes No If taking medications, please list the names of the medication(s): Has the patient ever taken any prescribed diet medication(s)? * Required Yes No If yes, please list the names of the diet medication(s): Is the patient allergic to any medication(s)? * Required Yes No If allergic to medications, please list the names of those medication(s): Does the patient have a latex allergy? * Required Yes No Does the patient have an acrylic allergy? * Required Yes No Does the patient have a metal allergy? * Required Yes No Does the patient have a local anesthetic allergy? * RequiredSuch as Lidocaine. Yes No Does the patient have history of eating disorders? * RequiredSuch as Anorexia or Bulimia. Yes No Has the patient had theirs tonsils and/or adenoids removed? * Required Yes No Has the patient had a serious illness or been hospitalized? * Required Yes No If the patient has had a serious illness, please explain: Has the patient ever been advised by a physician to take an antibiotic prior to any dental procedures? * Required Yes No If yes, please list the antibiotic name and method: Has the patient ever had a severe head or facial injury? * Required Yes No If yes, please explain the face injury: Does the patient have any disease, condition, or problems not listed that we need to be aware of? * Required Yes No If yes, please explain the disease, condition, or problem: Please use space below to provide any helpful information. Feel free to include any questions you may have: Authorization of ReleaseHuntersville Smiles Orthodontics is authorized to release protected health information about the below-named patient in the following manner and to identified person. I understand the following information including but not limited to appointment, medical, treatment and financial details may be discussed via whatever form of communication I list below. I understand E-Mail and Text communication may not be sent in an encrypted manner and there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication. Name of Patient * Required Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Name * Required Relationship to Patient * Required Mother Step-Mother Father Step-Father Guardian Who can Huntersville Smiles provide information on your behalf?Name * Required Relationship to Patient * Required Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail) * RequiredEmail * Required Add another contact? * Required Yes No Name Relationship to Patient Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail)Email Add another contact? Yes No Name Relationship to Patient Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail)Email Add another contact? Yes No Name Relationship to Patient Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail)Email Patient RightsI have the right to revoke this authorization at any time by contacting our office at (704) 456-9166. I may inspect or copy the protected health information to be disclosed as described in this document. Revocation is not effective in cases where the information has already been disclosed but will be effective going forward. Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. The information is released at the patient’s request and this authorization will remain in effect until revoked by the patient. Signature of Parent/Guardian * Required Reset signature Signature locked. Reset to sign again Please provide signature for Authorization of Release. Acknowledgement Of Receipt Of Notice Of Privacy PracticesBy signing my name to this online form, I certify that I have read the information and that any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the policies or guidelines. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request.Signature of Parent/Guardian * Required Reset signature Signature locked. Reset to sign again Please provide signature for Acknowledgement Of Receipt Of Notice Of Privacy Practices. SignatureI attest that this form has been completed in its entirety and agree that the information given is to be true and accurate. If applicable I grant permission to Huntersville Smiles Orthodontics to bill the given insurance policy or policies and directly receive payment(s) for procedure(s) and/or treatment. THE OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY ISSUES THAT MAY OCCUR DUE TO PROVIDING INADEQUATE OR FALSE INFORMATION. Signature of Parent/Guardian * Required Reset signature Signature locked. Reset to sign again
