Welcome to Our Offi ce
IS THERE SOMEONE OTHER THAN YOUR DENTIST WHOM WE MAY THANK FOR REFERRING YOU TO OUR OFFICE? (FRIENDS, NEIGHBORS, PATIENTS, ETC.?)
Information For Patients Who Are MINORS:
Parents' Marital Status: ❑ Married ❑ Separated ❑ Widowed ❑ Divorced (if divorced, who has custody of child? )
Responsible Party Information (to be completed by all adult patients and the parent/guardian of patients who are minors) Responsible Party #1 Responsible Party #2 MEDICAL HISTORY Name & Address of patient's physician
Is the patient in good health? ❑ Yes ❑ No If No Please Explain:
Any serious accidents, operations, or unusual illnesses: ❑ Yes ❑ No
Currently under physician's care? ❑ Yes ❑ No If Yes Please Explain:
Does the patient have an artifi cial heart valve, a history of endocarditis, any other serious congenital heart condition (includ-ing heart transplant) or any other medical condition that requires being premedicated with antibiotics prior to dental treat-ment? ❑ Yes ❑ No (If yes, please explain
Does the patient take (or have they ever taken) a bisphosphonate drug such as Fosamax, Boniva, Actonel, etc. that is used to treat osteoporosis or other bone disorders? ❑ Yes ❑ No
Does the patient use non-steroidal anti-infl ammatory drugs (NSAIDS) such as Ibuprofen/Advil, Naproxen, Relafen, etc. on a daily basis? ❑ Yes ❑ No
Please indicate whether or not the patient has or had any of the following: Growth/Family History Information For Patients Under 18 Years of Age Child's Height:
Is there any family history of a strong lower jaw and/or underbite? ❑ No ❑ Yes
Names and Ages of Patient's Brothers and Sisters?
Have any had Orthodontic Treatment? ❑ No ❑ Yes When?
❑ ❑ Is the patient currently in orthodontic treatment? Name & address of orthodontist:❑ ❑ Has the patient consulted an orthodontist previously? Name & address of orthodontist:❑ ❑ Has the patient ever had gum disease?
❑ ❑ Has the patient had any severe head or face injuries? Explain:❑ ❑ Has the patient had a history of thumb sucking or fi nger sucking? Stopped? When?❑ ❑ Does the patient play any musical (wind) instruments? What?❑ ❑ Have you ever been informed of missing or extra permanent teeth?❑ ❑ Does the patient's jaw ever get "stuck" or "locked" or have diffi culty opening his/her mouth?❑ ❑ Do the patient's jaw joints ever "pop" or make noise? How often?______________❑ ❑ Does the patient have jaw joint pain? How often? __________________❑ ❑ Has the patient previously been treated for jaw joint ("TMJ") problem?
Why are you seeking orthodontic consultation?
Is there any other information which may be helpful?
Please read the following regarding our fi nancial policies:
In separation/divorce situations, the individual who initiates services with us is held fi nancially responsible. We do not bill another person or an estranged spouse unless that individual informs us in writing of his or her willingness to pay for services. Even when another party or estranged spouse is billed, the person initiating treatment is ultimately responsible should the other party fail to pay.
Please note that our offi ce is very willing to help out with the fi ling of insurance and, in most cases, we will fi le the primary insurance for you and accept the assignment of benefi ts. In the case of secondary insurance, we will gladly assist you in fi ling it but due to the uncertainty of secondary coverage, our offi ce policy is to have secondary insurance benefi ts paid to the patient.
In the event of a denied insurance claim, we will do our best to help you work things out with the insurance company but any insurance dispute is ultimately between the insured and the insurance company. If a claim remains unpaid despite our good faith effort to fi le it, the responsible party is ultimately responsible for payment of the entire account balance - including that part not paid by the insurance company.
I have read and understand the fi nancial policies listed above.
ISF Rule Changes 2010 – 2014 RULE 1, SECTION 6 DESCRIPTION: DESCRIPTION: (FP and SP) A base on balls permits a batter to gain A live or dead ball appeal is a play or situation on first base without liability to be put out and is which an umpire cannot make a decision unless awarded to a batter by the plate umpire when four requested by a Manager, Coach or infielder p
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