Health History/HIPAA/Communication Authorization/Media Consent - Cupertino

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HEALTH/DENTAL HISTORY

Reviewed by Doctor:

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Month

Day

Year

Hour

Minute

AM/PM

What helped you decide to come to Cupertino Ortho Care?

Friends Family Social Media Our Website Online Reviews Other

Other:

Family or Friend's Name:

The following information is for a(n):*

Adult Child

Sex:*

Male Female

Patient's First Name:*

Patient's Last Name:*

Prefers to be addressed as:

Date of Birth:

School Name:*

Grade Level:*

Home Phone #:*

Cell Phone #:

Cell Phone Carrier:

Is texting permitted?

Yes No

Email:*

Home Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Employed by:

Occupation:

Work Phone:

Parent/Partner's Information

Parent's Name:*

Parent's Employer:

Parent's Occupation:

Parent's Best Phone #:

Parent's Address (if different from patient):

Address Line 1

Address Line 2

City

State

ZIP Code

Parent's Email Address:

Parent/Partner's Information

Parent's Name:

Parent's Employer:

Parent's Occupation:

Parent's Best Phone #:

Parent's Address (if different from patient):

Address Line 1

Address Line 2

City

State

ZIP Code

Parent's Email Address:

Marital Status:*

Single Married Divorced Separated Widowed

Parents' Marital Status:*

Single Married Divorced Separated Widowed

Guardian's Information (if applicable)

Guardian's Name:

Guardian's Employer:

Guardian's Occupation:

Guardian Phone:

Guardian's Email:

Spouse's Name:

Spouse Occupation:

Best Phone # to Be Reached:

Spouse's Employer

Person Responsible for Account:*

Father Mother Guardian Other

Person Responsible for Account:

Self Spouse Other

Name of person responsible:

Address (if different from patient):

Home Phone:

Business Phone:

Cell#

Does the patient have siblings?

Yes No

Sibling's Name (1):

Siblings date of birth (1):

Sibling's Name (2):

Siblings date of birth (2):

Sibling's Name (3):

Siblings date of birth (3):

Contact in case of Emergency (Name):*

Phone:*

Cell#:

What is Most Important

We recognize that each patient family has individual needs and expectations.

Our Goal is to Meet and Exceed Yours!

Please briefly describe what is most important to you/your family in choosing an orthodontic specialist.

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.*

Agree

Click here to read the HIPAA Consent Policy

Photographic / Media / Social Media Consent

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Cupertino Ortho Care and their affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).
I hereby consent to the collection and use of my personal images by photography or video recording.
I further acknowledge that Cupertino Ortho Care may use my image in media to promote the practice in the future.
I understand that no personal information, such as names, will be used in any publications unless express consent is given.
I also understand that my consent can be withdrawn at anytime in writing to Cupertino Ortho Care.

I have read the above statements and I give this consent voluntarily.*

Agree Do Not Agree

Authorization for Cell Phone and Email Use

I give my consent to receive regular unencrypted email communications regarding treatment information, insurance, account and billing information, and for regular unencrypted email correspondence with my dentist. I understand that I can withdraw my consent at any time.*

Agree Do not agree

Choose All that apply:*

Phone Calls Text Email Neither

Certification:*

I certify that I am the authorized representative for the patient. I certify that I am the patient

My relationship to the patient is:

DENTAL INSURANCE

Do you have Dental Insurance?*

Yes No

Primary Dental Insurance Co:*

Dental Insurance Co Phone #:*

Member ID:*

Ortho Coverage:

Yes No

Primary Insurance Subscriber's Name:*

Relationship to patient*

Group #:*

Subscriber's SSN:*

Birthdate:*

Do you have Secondary Insurance?*

Yes No

Secondary Dental Insurance Co:*

Member ID:*

Ortho Coverage:

Yes No

Insurance Subscriber's Name:*

Birthdate:*

YOUR DENTAL HISTORY

Do you have a Dentist?*

Yes No

Patient Dentist Name:*

Date of Last Visit:

Have there been any injuries to the face, mouth or teeth?*

Yes No

Explain your injury:

Have you had or do you presently have any of the following habits?*

Thumb or finger sucking Lip Biting Snoring Grinding of the teeth at night Mouth breathing Other None

Other habits:

Have you been informed of any missing or extra permanent teeth?*

Yes No

Are you aware of sores, lumps or irritated areas in the mouth?*

Yes No

Has an orthodontist been consulted previously?*

Yes No

Orthodontist's Name:

Date:

Have you ever been treated for:*

Bad Bite TMJ Periodontal disease None

Doctors Name:

Do you have bleeding gums?*

Yes No

Do you have any speech problems?*

Yes No

Reason for consultation (chief concern):*

Has there ever been any orthodontic treatment for any other member of your family?

Child Spouse Other Family Member

Child's Doctor:

Stage of Treatment:

Were they satisfied with the results?

Yes No

Spouse's Doctor:

Stage of Treatment:

Were they satisfied with the results?

Yes No

What is the name of your family physician?

Date of last physical:

Are you taking any medication?*

Yes No

Medication Names:

Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)*

Yes No

List allergies:

Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?*

Yes No

Antibiotic name and method:

Pharmacy:

DO YOU HAVE NOW, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

(Please check if YES or leave unchecked for NO)

Please check if YES or leave unchecked for NO:

ADD/ADHD AIDS OR H.I.V. POSITIVE ARTHRITIS ASTHMA AUTISM BIRTH CONTROL BISPHOSPHONATES (OSTEOPOROSIS) BLOOD DISORDERS/BLEEDING PROBLEMS BONE DISORDERS CANCER THERAPY CONGENITAL HEART DISEASE DIABETES EARACHES EMOTIONAL PROBLEMS ENDOCARDITIS EPILEPSY FAINTING SPELLS HANDICAP/DISABILITIES HEADACHES

Please check if YES or leave unchecked for NO:

HEART CONDITION HEPATITIS HERPES (ORAL-COLD SORES) HIGH BLOOD PRESSURE IMPAIRED HEARING INFLAMMATORY RHEUMATISM JAW ISSUES/PAIN KIDNEY TROUBLE LIVER DISEASE PREGNANT PSYCHIATRIC TREATMENT RESPIRATORY LUNG DISEASE SINUS PROBLEMS SLEEP APNEA STROKE TEETH GRINDING ULCERS X-RAY/RADIATION (CANCER) THERAPY OTHER

Hepatitis Type:

List Other Medical Issues:

Notes:

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

Cupertino Ortho Care may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.

Signature*

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