Adult HHF | Charlotte Braces (Z&G) – Forms

Step 1 of 10

New Patient Form
We 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
Email * Required
Cell Phone * Required
Preferred method of communication * Required
- Home Phone
- Cell Phone
- Text / SMS
- Email

Patient Information
Nickname
Gender * Required
- Male
- Female
Hidden
Marital Status * Required
- Single
- Married
- Divorced
- Widowed
Address * Required
Street Address Address Line 2 City State Zip Code
Birthdate * Required
Age * Required
Home Phone * Required
Work Phone
Other family members seen in our office
Other Information
Employer * Required
Employer Address * Required
Street Address City Zip Code
Who may we thank for referring you to our office?
Do you have a spouse or emergency contact we should know about? * Required
- Yes
- No

Spouse / Emergency Contact Information
Name * Required
First Middle Initial Last
Hidden
Gender * Required
- Male
- Female
- Prefer Not to Answer
Hidden
Marital Status * Required
- Single
- Married
- Divorced
- Widowed
Hidden
Email * Required
Hidden
Birthdate * Required
Hidden
Spouse Relationship to Patient * Required
Cell Phone * Required
Other Information
Employer * Required
Employer Address * Required
Street Address City Zip Code

Dental Insurance
Do you have dental insurance? * Required
- Yes
- No

Dental Insurance Information
Subscriber Name * Required
Relationship to Patient * Required
Subscriber Birthdate * Required
Insured's Employer * Required
Insurance Company Name * Required
Insurance Phone * Required
Group Number * Required
ID Number * Required
Insurance Company Address * Required
Street Address City State Zip Code
Do you have secondary dental insurance? * Required
- Yes
- No

Secondary Dental Insurance Information
If 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 * Required
Relationship to Patient * Required
Subscriber Birthdate * Required
Insured's Employer * Required
Insurance Company Name * Required
Insurance Phone * Required
Group Number * Required
ID Number * Required
Insurance Company Address * Required
Street Address City State Zip Code

Authorization of Release
Zammitti & Gidaly 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 above.
- 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.
How can Zammitti & Gidaly communicate with you?
Email * Required
Phone (Mobile/SMS) * Required
Phone (Voicemail) * Required
Other
Who can Zammitti & Gidaly provide information on your behalf?
Name
Relationship
Phone (SMS/Voicemail)
Email
Opt-Out
Only select if you do NOT want any information released to family or friends.
What information may we share with this person?
- Medical/Treatment
- Financial
- Appointment Details
Patient Rights
- I have the right to revoke this authorization at any time by contacting our office at 704-947-9991.
- 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 Patient * Required
Please provide signature for Authorization of Release.

Acknowledgement Of Receipt Of Notice Of Privacy Practices
By 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 Patient * Required
Please provide signature for Acknowledgement Of Receipt Of Notice Of Privacy Practices.

Signature
I 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 Zammitti & Gidaly 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 INFORMATION. 
Signature of Patient * Required

Step 1 of 10

New Patient Form

Patient Information

Other Information

Spouse / Emergency Contact Information

Other Information

Dental Insurance

Dental Insurance Information

Secondary Dental Insurance Information

Dental History

Have you ever HAD or PRESENTLY HAVE any of the following habits?

Medical History

Have you ever HAD or PRESENTLY HAVE any of the following?

Authorization of Release

How can Zammitti & Gidaly communicate with you?

Who can Zammitti & Gidaly provide information on your behalf?

Patient Rights

Acknowledgement Of Receipt Of Notice Of Privacy Practices

Signature