Limbaugh Ortho

Which form are you using?*

Adult

Child

Patient Information (Adult)

Name*

Preferred Name

Gender*

Male

Female

Date of Birth*

Social Security Number

Cell Phone*

Home Phone

Street Address*

City*

State*

ZIP Code*

Email*

How many years at this address?*

Employer

Occupation

Employer's Street Address

Employer's City

Employer's State

Employer's ZIP Code

Work Phone

Number of years employed?

Whom may we thank for referring you?

Valpak

Dentist

Google

Website

Friend

Family

Other

Name of Friend*

Name of Family Member*

Name of Referral*

Marital Status*

Spouse Information

Spouse's Name*

Spouse's Date of Birth*

Social Security Number

Employer

Occupation

Employer Street Address

City

State

ZIP Code

Employer's Work Phone

Numer of Years Employed?

Spouse's Work Phone

Spouse's Cell Phone*

Email*

Patient Information (Child)

Name*

Preferred Name

Gender*

Male

Female

Date of Birth*

School Attends*

Grade*

Street Address*

City*

State*

ZIP Code*

Cell Phone*

Home Phone

Name/Relationship of person accompanying patient to today's appointment*

Patient Lives With Whom?*

Names please.

Relationship To The Patient*

Parent, Step-Parent, Grand Parent, etc.

Who Has The Legal Custody Of The Patient?*

Names please.

Names Of Siblings and Birthdates

Name

Birthdate

Whom my we thank for referring you?

Valpak

Dentist

Google

Website

Friend

Family

Other

Name of Friend*

Name of Family Member*

Name of Referral*

Responsible Party

Who will be the primary responsible party for the patient’s orthodontic treatment?*

Both Parents

Mother only

Father only

Guardian

Marital Status of Responsible Party?*

Mother's Information

Same address as patient

Mother's Name*

Mother's Relationship*

Parent

Guardian

Step Mother

Mother's Date of Birth*

Mother's Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Mother's Work Phone

Mother's Cell Phone*

Mother's Employer

Years Employed

Mother's Occupation

Mother's Email*

Father's Information

Same address as patient

Father's Name*

Father's Relationship*

Parent

Guardian

Step Father

Father's Date of Birth*

Father's Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Father's Work Phone

Father's Cell Phone*

Father's Employer

Years Employed

Father's Occupation

Father's Email*

Guardian's Information

Guardian's Gender*

Male

Female

Male

Same address as patient

Guardian's Name*

This field is hidden when viewing the form

Relationship to Patient*

Father

Guardian

Step Father

Guardian's Date of Birth*

Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Cell Phone*

Work Phone

Employer

Years Employed

Occupation

Email*

Female

Same address as patient

Guardian's Name*

This field is hidden when viewing the form

Relationship to Patient*

Mother

Guardian

Step Mother

Guardian's Date of Birth*

Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Cell Phone*

Work Phone

Employer

Years Employed

Occupation

Email*

Primary Insurance Information

Insurance?

Check here if no orthodontic coverage will be applied

Insurance Company*

Insurance Phone Number*

Employer/Group Name*

Group Number*

Subscriber/Employee*

Subscriber ID/SSN*

Subscriber's Date of Birth*

Relationship To Patient*

Photo of front of Insurance Card

If using a mobile phone or tablet to complete this form, you can use this button to snap a photo of the card. Otherwise, you may upload a photo of it here.

Accepted file types: jpg, gif, png, Max. file size: 40 MB.

Photo of back of Insurance Card

If using a mobile phone or tablet to complete this form, you can use this button to snap a photo of the card. Otherwise, you may upload a photo of it here.

Accepted file types: jpg, gif, png, Max. file size: 40 MB.

Secondary Insurance Information

Secondary Insurance?

Check here if no secondary insurance

Insurance Company*

Insurance Phone Number*

Employer/Group Name*

Group Number*

Subscriber/Employee*

Subscriber ID/SSN*

Subscriber's Date of Birth*

Relationship To Patient*

Emergency Contact Information

Nearest Relative Not Living With Patient*

Nearest Relative's Relationship To Patient*

Nearest Relative's Cell Phone*

Nearest Relative's Home Phone

Medical History

Please Read:

We are passionate about our mission to give everyone a great smile. Please help us help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.

Physician's Name*

Physician's Phone*

Date of last physical exam

Is the patient under medical treatment now?*

Yes

Has the patient been hospitalized for any surgical operations or serious illness in the past five years?*

Yes

Please describe the surgical operation(s) or illness(es).*

Is the patient taking medication(s) including non-prescription medicine?*

Yes

If yes, what medications is the patient taking?*

Does the patient use tobacco?*

Yes

Is the patient aware of being allergic to any medications or substance including metals?*

Yes

If yes, what?*

Has the patient ever taken Bisphosphonates (EX: Fosamax) for Osteoporosis?*

Yes

If yes, specify

Has the patient reached puberty?*

Yes

Has menstruation begun?*

Yes

If yes, please date*

Is the patient pregnant or think they may be?*

Yes

Does the patient have or have they had any of the following?

If taking medication, please specify:

Dental History

Dentist's Name*

Date of last cleaning? (approximate)

Is the patient anxious or nervous about dental treatment?*

Yes

Does the patient require premedication for dental treatment?*

Yes

Does the patient feel pain in any of their teeth?*

Yes

Does the patient have any sores or lumps in or near their mouth?*

Yes

Has the patient had any head, neck, or jaw injuries?*

Yes

If the patient has had any head, neck, or jaw injuries, please describe:*

Does the patient have any ongoing problems in their jaw with:

Chronic clicking or popping?

Pain?

Difficulty opening or closing?

Difficulty in chewing?

Does the patient clench or grind their teeth?*

Yes

Does the patient bite their lips or cheeks frequently?*

Yes

Has the patient ever had speech therapy?*

Yes

Please describe the patient's speech therapy?*

Is there any outstanding dental Treatment to be completed?*

Yes

If yes, there is outstanding dental Treatment to be completed, describe:*

Has the patient ever had instruction on the correct method of brushing and flossing their teeth?*

Yes

Does the patient have any of the following oral habits:

Nail biting?

Thumb sucking?

Tongue thrust while swallowing?

Mouth breathing?

How many times a day does the patient brush?*

Please check the boxes below which describe the problem(s) for which the patient is seeking treatment for:*

Crowding

Extra space

Teeth stick out too far

TMJ problems

Poor bite relationship

Missing teeth

Teeth erupting in the wrong position

Extra permanent teeth

Other

What other problem:*

Has the patient had an orthodontic Evaluation or treatment before?*

Yes

If so, when and by whom?*

Privacy Notice

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.

Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

To other health care providers (i.e. your dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e. to determine the result of cleaning, surgery, etc);
To third party payors or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of you account (i.e. to determine benefits, dates of payment, etc);
To certifying, licensing and accrediting bodies (i.e. the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
Internally, to all staff members who have a role in your treatment;
To other patients and third parties who may see or over hear incidental disclosures about your treatment, scheduling, etc.;
To your family and close friends involved in your treatment; and/or,
We may contact you to provide appointment reminders or information about your treatment alternatives or other health- related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

Request restrictions on the use and disclosure of your protected health information;
Request confidential communication of your protected health information;
Inspect and obtain copies of your protected healthy information through asking us;
Amend or modify your protected health information in certain circumstances;
Receive an accounting of certain disclosures made by us of your protected health information; and,
You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquires to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed with 180 days of the violation).

We have the following duties under the privacy rules:

By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
To abide by the terms of our Privacy Notice that is currently in effect;
To advise you of our right to change the terms of the Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us and that if we do some, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:

Honor any requests by you to restrict the use or disclosure of your protected health information;
Amend your protected health information if, for example, is accurate and complete; or,
Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

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

Privacy Consent

This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to your orthodontic treatment, you should review, sign and date this form.

Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e. performance reviews, certification, accreditation and licensure)

You have the right to review our office’s privacy notice prior to signing this Consent, a copy of which was given to you with this Consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.

Thank you for your cooperation. Please let us know if you have any questions.

Authorization and Release

TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED AND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE LIMBAUGH ORTHODONTICS PERMISSION TO PERFORM AN ORTHODONTIC EXAMINATION.

Print Name*

This is name of person filling out the form and providing signature.

Relationship to Patient*

Signature of Patient (or Parent if minor)*

Comments

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