Medical Dental History Form for Adult Patients

Thank you for choosing our office for your orthodontic needs. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party. We are fully compliant with all HIPAA Regulations.
Note: The patient is responsible for payment at the time of service.

(*) indicates a required field.

Tell Us About Yourself

Date *

Patient's Last Name *

First Name *

Middle Initial *

Title*
Mr. Mrs. Ms. Miss. Dr.

I prefered to be called

Birthdate *

Sex *

Marital Status *

Street Address *

City *

State *

Zip Code *

Time at Residence

Cell Number *

Work Number

Email Address(es) *

Employer

Occupation

Time at Employer

Closest Relative

Spouse or closest relative name(s)

Title

Relationship to Patient

Address (if different than patient address)

Cell Number

Dentist

Patient's Dentist

Address, City, State

Last Seen

Reason

Next Appointment

General Information

What concerns you about your teeth

Who suggested that you might need orthodontic treatment

Have you had any previous orthodontic treatment? Please describe

Have any other family members been treated in this office? Please name them

How did you hear about us?

Dental Insurance

Primary Policy Holder's Full Name

Policy Holders Birthdate

ID #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance Company

Group # (Plan, Local or Policy #)

Does this policy have orthodontic benefits?

Yes No Don't know

Secondary Policy Policy Holder's Full Name

Birthdate

ID #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance Company

Group # (Plan, Local or Policy #)

Patient Health Information

List any medications, nutritional supplements, herbal medications or non-prescription medicines including flouride supplements, that you take

Medication

Taken For

Medication

Taken For

Do you take any antibiotic pre-medication before any dental procedures?

Do you chew or smoke tobacco?

Have you noticed any changes in your face or jaws?

Any other physical problems?

How often do you brush?

How often do you floss?

Women: Are you prenant?
Yes No

Are you trying to become pregnant?
Yes No

Release and Waiver

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Signature of Patient *
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

I have read the above questions and understand them. I will not hold my orthdontist or any member of his/her staff responsible for any errors or omission that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

Signature of Patient *
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

Medical History

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark Yes, No, or Don't Know/Understand (DK/U)

Now or in the past, have you had:

Birth defects or hereditary problems?

Yes No DK/U

Bone fractures or major injuries?

Yes No DK/U

Any injuries to face, head, or neck?

Yes No DK/U

Arthritis or joint problems?

Yes No DK/U

Endocrine or thyroid problems?

Yes No DK/U

Diabetes or low sugar?

Yes No DK/U

Kidney problems?

Yes No DK/U

Cancer, tumor, radiation treatment or chemotherapy?

Yes No DK/U

Stomach ulcer, hyperactivity, acid reflux?

Yes No DK/U

Immune system prombles?

Yes No DK/U

History of osteoporosis?

Yes No DK/U

Seizures, fainting spells, neurologic problems?

Yes No DK/U

Mental health disturbance or depression?

Yes No DK/U

Vision, hearing, or speech problems?

Yes No DK/U

High or low blood pressure?

Yes No DK/U

Excessive bleeding or bruising, anemia?

Yes No DK/U

Chest pain, shortness or breath, tire easily, swollen ankles?

Yes No DK/U

Heart defects, heart mumur, theumatic heart disease?

Yes No DK/U

Angina, artiosclerosis, stroke or heart attack?

Yes No DK/U

Skin disorder (other than common acne)?

Yes No DK/U

Frequent headache or migraines?

Yes No DK/U

Frequent ear infections, colds, throat infections?

Yes No DK/U

Asthma, sinus problems, hayfever?

Yes No DK/U

Tonsil or adenoid condition?

Yes No DK/U

Do you frequently breath through your mouth?

Yes No DK/U

Have you had allergies or reactions to any of the following?

Local anesthetics (novocaine, lidocaine, xylocaine)?

Yes No DK/U

Latex (gloves, balloons)?

Yes No DK/U

Metals (jewelry, clothing snaps)?

Yes No DK/U

Penicillin?

Yes No DK/U

Other antibiotics?

Yes No DK/U

Ibuprofen (Motrin, Advil)?

Yes No DK/U

Other

Dental History

Now or in the past, have you had:

Permanent or extra (supernumerary) teeth removed?

Yes No DK/U

Supermumeray (extra) or congenitally missing teeth?

Yes No DK/U

Chipped or injured primary or permanent teeth?

Yes No DK/U

Any sensitive or sore teeth?

Yes No DK/U

Bleeding gums, bad taste or mouth odor?

Yes No DK/U

Jaw fractures, cysts, injections?

Yes No DK/U

Any teeth treated with root canals or pulpotomies?

Yes No DK/U

History of speech problems or speech therapy?

Yes No DK/U

Difficulty breathing through nose?

Yes No DK/U

Have you ever been diagnosed with gum disease?

Yes No DK/U

Mouth breathing habit or snoring at night?

Yes No DK/U

Frequent oral habbit (sucking finger, chewing pen, etc)?

Yes No DK/U

Teeth causing irritation to lip, cheek or gums?

Yes No DK/U

Abnormal swallowing (tongue thrust)?

Yes No DK/U

Tooth grinding or clenching?

Yes No DK/U

Clicking, locking in jaw points?

Yes No DK/U

Soreness in jaw muscles or face muscles?

Yes No DK/U

Ringing in ears, difficulty in chewing or opening jaw?

Yes No DK/U

Have you ever been treated for TMJ or TMD problems?

Yes No DK/U

DIGITAL X-RAY AND PHOTO CONSENT

I,, consent to having digital x-rays and photos taken of (myself/child's name) for the purpose of an orthodontic consultation. I understand that all digital images, including photos and x-rays are the property of Dentistry Just for Kids + TK Orthodontics. Charges will be applied for the request or transfer of any records of patients that are not in treatment at our office.

Relationship to patient (or self)

Signature*
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

I,, relinquish any and all rights to photographs or other reproductions of, (myself/child's name) captured with still motion picture, video, digital, or other cameras used by Dentistry Just for Kids + TK Orthodontics. I also allow any photos taken to appear on Dentistry Just for Kids + TK Orthodontics Facebook page and Website.

Relationship to patient (or self)

Signature*
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

APPOINTMENT CANCELLATION POLICY

Dentistry Just for Kids + TK Orthodontics (DJ4K+TKO) is privileged to provide dental services to our family of patients. We respect your time and make every effort to keep you from waiting. As a result, your appointment time in our office is reserved exclusively for you.
We understand that emergencies arise, just as they do for us; however, when a patient fails an appointment without notice, we cannot use that time to meet the needs of other patients.

Confirm your appointment. DJ4K+TKO will contact you multiple times prior to your appointment by text, email and telephone. You must reply to one of these reminders to confirm your appointment.

(initials)

Late Arrivals: When we reserve time for you, we require all of that reserved time to provide you the best quality dental treatment. If you arrive more than 15 minutes late, your appointment may be rescheduled in order to meet the needs of those who are on time. If this happens, it will be considered a Missed Appointment and the fees may apply as listed below.

(initials)

Cancellations/Rescheduled Appointments: If you need to cancel or reschedule your appointment, we require at least a 48 hour notice. This process will give another patient the possibility of utilizing that reserved appointment. Cancellations may not be called into our answering service or via email.

(initials)

No Show/Missed Appointment:A “No Show” or Missed Appointment occurs when a patient misses an appointment without cancelling at least 48 hours in advance. The account will be charged a fee of $50.00. If there is a second “No Show”, a $100.00 fee will be applied to your account. No future appointments will be scheduled without the payment of the fee. A third “No Show” may result in dismissal from the practice.

(initials)

Medicaid/Hoosier Healthwise Missed Appointments: All missed appointments will be reported to Medicaid and may result in dismissal from the Practice.

(initials)

I have read, understand and accept the above Policies. I also understand and agree that such terms may be amended from time-to-time by the Practice.

Signature*
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

FINANCIAL POLICY

We are very pleased to welcome you to Dentistry Just for Kids + TK Orthodontics (DJ4K+TKO). Our goal is to provide you with the highest quality dental care in a fun and enjoyable environment. Listed below is our financial policy.

Payment for professional services is due at the time dental services are provided. It is our policy to make every effort to provide financial arrangements with you before treatment begins; however, this is only an estimate. We accept cash, checks, debit cards and most major credit cards. We also have several resources for payment options available to help you begin treatment as soon as possible.
If you have dental insurance, we will be happy to file your claim on your behalf. Please be familiar with your insurance benefits as we will collect the estimated amount insurance is not expected to pay, including all fees considered above insurance company’s usual and customary fee schedule. Any remaining balances will be billed to you after the claim is paid. Please understand that we file dental insurance as a courtesy to our patients. Our office will make every reasonable effort to obtain payment from your insurance company but you will be ultimately responsible for all outstanding balances.
Some dental plans do not allow payments to non-providers; the insurance company sends the payments directly to you. We will file your insurance for these companies; however, you may be required to pay in full at time of service.
The responsible party is responsible for any balances whether insurance has paid or not after 30 days. Past due accounts will be notified via statements by mail. If the account remains unpaid, we may employ a collection service to collect payment. If the balance is not paid within 90 days, finance charges will be applied each month until paid. For patients who have been in collection in the past, payment will be due IN FULL at time of service. There is a $30.00 service charge on all returned checks.
The parent or guardian who brings a minor in for their initial visit is the responsible party. This parent or guardian is required to pay for professional services regardless of the provisions in the divorce decree, or who has custody, or who has the insurance. Guardianship paperwork must be provided at the initial visit.

AUTHORIZATION

I hereby give permission to DJ4K+TKO to render all necessary dental services and undertake any diagnostic measures to facilitate treatment for the patient listed below. Furthermore, I will be responsible for any fees incurred for dental treatment and authorize the release of any information to my insurance company. I understand that some or all of the dental charges may not be covered by my insurance. I unconditionally agree to be responsible and pay DJ4K+TKO for any and all charges not covered by insurance. I agree that in the event I do not payment the amounts due DJ4K+TKO, my account will be placed in the hands of an attorney for collection proceedings. I will be responsible for all attorney fees, court costs, collection costs, consideration for assignment, litigation expenses, as well as any other incidental expenses incurred by DJ4K+TKO.
I have read and accept the above Financial Policy and Authorization and understand it and agree to the terms set forth regarding payment.

Signature*
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

Patient Name

Patient or Responsible Party Name

Protected Health Information

Patient Name:

Date of Birth

I request that the following information of my Protected Health Information or my child’s Protected Health Information to be released. (Protected Health Information would include your/child’s name, diagnoses, dates of service as described in the Notice of Privacy Practices). Dentistry Just For Kids + TK Orthodontics may disclose information by telephone or in person to the people listed below. This document does not allow the people listed below to receive medical records.

Name

Phone Number

Relationship

I do not wish to have my Protected Health Information or my child’s Protected Health Information disclosed.

Patient Signature (or Parent/Legal Guardian Signature if patient is under 18 years old)*
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date

Acknowledgement Receipt of Notice of Privacy Practices

**You May Refuse to Sign this Acknowledgement**

I have been informed of this office’s Notice of Privacy Practices.

Name:

Date

Signature*
(Please use your mouse or finger on a touchscreen to sign in the box.)