Patient Information

* First Name:
MI:
* Last Name:
Nickname:
* Date of Birth:
* Gender:
* Street:
* City:
* State:
* Zip:
* Main Phone:
Mobile Number:
Email:
I would like to receive text message reminders about appointments:
What are your hobbies/activities:
Cell phone carrier:
Employer:
Occupation:
No. of Years Employed:
Social Security #:

Whom may we thank for referring you to our office?
Please list the names of any friends or family currently in the practice:

Responsible Party Information

Responsible Party 2/Guardian 2

* First Name:
Middle Name:
* Last Name:
Nickname:
* Date of Birth:
Mobile Number:
* Address:
* City:
* State:
* Zip:
I would like to receive text message reminders about appointments:
Cell phone carrier:
Employer:
Occupation:
Length of Employment:
Social Security #:

Self/Responsible Party 1/Guardian 1

* First Name:
Middle Name:
* Last Name:
Nickname:
* Date of Birth:
Mobile Number:
* Address:
* City:
* State:
* Zip:
I would like to receive text message reminders about appointments:
Cell phone carrier:
Employer:
Occupation:
Length of Employment:
Social Security #:

Dental Insurance Information

Primary Insured Name:
Insured Social Security:
Insurance Company:
Insurance Co. Phone No.:
Policy #:
Group #:
Date of Birth:

Insurance Company Address

Address:
City:
State:
Zip:

Secondary Insured Name:
Insured Social Security:
Insurance Company:
Insurance Co. Phone No.:
Policy #:
Group #:
Date of Birth:

Medical History

Name of Physician/and their specialty:
Most Resent Physical Exam:
Purpose of Physical Exam:
What is your estimate of your general health?
DO YOU HAVE or HAVE YOU EVER HAD:

* Hospitalization for illness or injury
Allergies or drug reaction to:
* Aspirin, ibuprofen, acetaminophen, codeine
* Penicillin or other antibiotics
* Erythromycin
* Tetracycline
* Sulfa
* Local anesthetic
* Fluoride
* Latex
* Metals (nickel, gold, silver)
* Other:
* Jaundice
* Heart problems, or cardiac stent within the last six months
* History of infective endocarditis
* Artificial heart valve, repaired heart defect(PFO)
* Pacemaker or implantable defibrillator
* Orthopedic implant(joint replacement)
* Rheumatic or scarlet fever
* Chemotherapy, immunosuppressive medication
* Psychiatric treatment
* Alcohol/recreational drug use
* Tumor, abnormal growth
* High or low blood pressure
* A stroke(taking blood thinners)
* Anemia or other blood disorder
* Prolonged bleeding due to a slight cut(INR>3.5)
* emphysema, shortness of breath, sarcoidosis
* Tuberculosis, measles, chicken pox
* Asthma
* Breathing or sleep problems
(i.e. sleep apnea, snoring sinus)
* Kidney Disease
* Liver disease
* Thyroid, parathyroid disease, or calcium deficiency
* Hormone deficiency
* Diabetes
HbAlc=
* Digestive disorders
(i.e. celiac disease,gastric reflux)
* Arthritis
* Autoimmune disease
(i.e. rheumatoid arthritis, lupus, scleroderma)
* Glaucoma
* Contact lenses
* Head or neck injuries
* Epilepsy, convullsions (seizures)
* Neurologic disorders(ADD/ADHD, prion disease)
* Viral infections and cold sores
* Any lumps or swelling in the mouth
* Hives, skin rash, hay fever
* STI/STD/HPV
* Hepatitis
Type
* HIV/AIDS
* Radiation Therapy
* Emotional difficulties
* Antidepressant medication
ARE YOU:
* Presently being treated for any other illness
* Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
* Taking medication for weight management
* Taking dietary supplement
* Often exhausted or fatigued
* Experiencing frequent headaches
* A smoker, smoked previously or use smokeless tobacco
* Considered a touchy/sensitive person
* Often unhappy or depressed
FEMALE - Taking birth control pills?
FEMALE - Pregnant?
MALE - Prostate disorders?
* High cholesterol or taking statin drugs
* Stomach or duodenal ulcer
* Osteoporosis/osteopenia
(i.e.taking bisphosphonates)
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.
(i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two years:

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Dental History

How would you rate the condition of your mouth?
Current Dentist:
How long have you been a patient? Months/Years:
Date of most recent dental exam:
Date of most recent x-rays:
Date of most recent treatment (other then cleaning):
I routinely see my dentist every:
What is your immediate concern?

PERSONAL HISTORY


Are you fearful of dental treatment? If so, how fearful on a scale of 1 (least) to 10 (most):
* Have you had an unfavorable dental experience?
* Have you ever had complications from past dental treatment?
* Have you ever had trouble getting numb or had any reactions to local anesthetic?
* Did you ever have braces, orthodontic treatment or had your bite adjusted?
* Have you had any teeth removed?

GUM AND BONE


Do your gums bleed or are they painful when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
Have you experienced a burning sensation in your mouth?

TOOTH STRUCTURE


Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Do you feel or notice any holes(i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting into sweets, or avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Do you frequently get food caught between any teeth?

BITE AND JAW JOINT


Do you have problems with your jaw joint? (pain, sounds, limited opening locking popping)
Do you feel like your lower jaw is being pushed back when you bite your teeth together?
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Are your teeth becoming more crooked, crowded, or overlapped?
Are your teeth developing spaces or becoming more loose?
Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
Do you place your tongue between your teeth or rest your teeth against your tongue?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench your teeth in the daytime or make them sore?
Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?

SMILE CHARACTERISTICS


Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

UNDERSTANDING YOUR HEALTH INFORMATION
Each time you visit our office, we make a record of your visit in order to manage the care you receive. We understand that the medical information that is recorded about you and your health is personal. The confidentiality and privacy of your health information is also protected under both state and federal law. This Notice of Privacy Practices describes how this office may use and disclose your information and the rights that you have regarding your health information.

How We Will Use or Disclose Your Health Information
Treatment: We will use your health information for treatment. For example, information obtained by the orthodontist or other members of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your orthodontist will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations, so the physician will know how you are responding to treatment. We will also provide your physician, or a subsequent healthcare provider, with copies of various reports that should assist him or her in treating you.

Payment: We will use your health information for payment. For example, a bill may be sent to you or your health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Health Care Operations: We will use your health information for our regular health care operations. For example, we may use information in your health record to assess the care and outcome in your case and others like it. This information will then be used in a continued effort to improve the quality and effectiveness of the services we provide.

Business Associates: We may enter into contracts with persons or entities known as business associates that provide services to or perform functions on our behalf. Examples include our accountants, consultants, and attorneys. We may disclose your health information to our business associates so they can perform the job we have asked them to do, once they have agreed in writing to safeguard your information.

Notification: We may use or disclose information to assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided to us, e.g., on an answering machine.

Communication with Family: We may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Appointment Reminders / Health Benefits: We may contact you to provide appointment reminders or information about treatment alternatives or other health benefits that may be of interest to you.

Funeral Directors and Coroners: We may disclose your health information to funeral directors, and to coroners or medical examiners, to carry out their duties consistent with applicable law.

Organ Procurement Organizations: Consistent with applicable law, we may disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Research: We may disclose your health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. We may also disclose your health information to people preparing to conduct a research project, so long as the health information is not removed from us. We may also use and disclose your health information to contact you about the possibility of enrolling in a research study.

Fundraising: We may contact you as part of our fundraising efforts; however, you may opt-out of receiving such communications.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers’ Compensation: We may disclose health information to the extent authorized by and to the extent necessary, to comply with laws relating to workers’ compensation or other similar programs established by law.

Public Health Activities: As required by law, we may disclose your health information to public health, or legal authorities, charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities: We may disclose your health information to health oversight agencies for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution, or agents thereof, health information necessary for your health and the health and safety of other individuals.

Judicial and Administrative Proceedings: We may disclose your health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided.

Law Enforcement Purposes / Serious Threat to Health or Safety: We may disclose your health information to enforcement officials for law enforcement purposes under certain circumstances and subject to certain conditions. We may also disclose your health information to prevent or lessen a serious and imminent threat to a person or the public (when the disclosure is made to someone we believe can prevent or lessen the threat) or to identify or apprehend an escapee or violent criminal.

Victims of Abuse, Neglect, and Domestic Violence: In certain circumstances, we may disclose your health information to appropriate government authorities if there are allegations of abuse, neglect, or domestic violence.

Essential Government Functions: We may disclose your health information for certain essential government functions (e.g., military activity and for national security purposes).

The following uses and disclosures will be made only with your authorization: (i) with limited exceptions, uses and disclosures of your health information for marketing purposes, including subsidized treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other uses and disclosures not described in this notice. You may revoke your authorization at any time in writing, except to the extent that we have taken action in reliance on the use or disclosure indicated in the authorization.

Your Health Information Rights

Although your health record is the physical property of this office, you have the following rights with respect to your health information:

You may request that we not use or disclose your health information for a particular reason related to treatment, payment, our general healthcare operations, and/or to a particular family member, other relatives or close personal friend. We ask that such requests be made in writing on a form provided by us. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it, except as provided below.

If you have paid for services out-of-pocket in full, you may request that we not disclose information related solely to those services to your health plan. We ask that such requests be made in writing on a form provided by us. We are required to abide by such a request, except where we are required by law to make a disclosure. We are not required to inform other providers of such a request, so you should notify any other providers regarding such a request.

You have the right to receive confidential communications from us by alternative means or at an alternative location. Such a request must be made in writing, and submitted to the Privacy Officer. We will attempt to accommodate all reasonable requests.

You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. If we maintain your health information electronically in a designated record set, you may obtain an electronic copy of the information. If you request a copy (paper or electronic), we will charge you a reasonable, cost-based fee.

If you believe that any health information in your record is incorrect, or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by us to make such requests. For a request form, please contact the Privacy Officer.

You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed six years), as required by law. We ask that such requests be made in writing on a form provided by us. Please note that accounting does not include all disclosures, e.g., disclosures to carry out treatment, payment, or healthcare operations and disclosures made to you or your legal representative or pursuant to an authorization. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee.

You have the right to be notified following a breach of your unsecured protected health information.

You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.

For More Information or to Report a Problem

You have the right to complain to us and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.

For more information or to file a complaint with us, contact our Privacy Officer by phone or mail as follows:

E & S Orthodontics Privacy Officer: Kelli Burton
Phone: 623-376-6464
E-Mail: info@esorthodontics.com
Address: 8273 W. Lake Pleasant Parkway, Ste. 209
Peoria, AZ 85382

To file a complaint with the Secretary of HHS, send your complaint to:

PACIFIC REGION OFFICE FOR CIVIL RIGHTS
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103

If you have any questions or want more information about this Notice of Privacy Practices, please contact our Privacy Officer.

EFFECTIVE DATE OF THIS NOTICE: August 25, 2016

I understand where appropriate, a credit report may be obtained. I also hereby authorize release of any information relating to this claim. And I also authorize payment of insurance benefits directly to E&S Orthodontics.

* E-Signature:
Preferred Location:
Date: