New Patient Form - Paige Orthodontics

Step 1 of 4 - PATIENT INFORMATION

PATIENT INFORMATION

Today's Date*

Patient's Name*

First Middle Last

Nickname

Date of Birth*

RESPONSIBLE PARTY INFORMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone

Second # if can't be reached at first #

Email*

Relationship with Patient*

DENTAL HISTORY

Does the patient have any dental issues?

NOTE: We make every attempt to schedule appointments for convenience, but orthodontics appointments may infringe on your school/ work schedule.

Please type your initials indicating that you understand about appointment scheduling:*

Date*

I understand that records are stored electronically and that an electronic copy shall be considered an original for all purposes.*

Yes

The use of dental photos and radiographs, or x-rays, allows the doctor to detect dental problems early before serious damage is done to you or your child’s teeth, gums, and supporting bones and structures. If these conditions are not detected until there are visible or painful signs of disease, you or your child’s oral health can be seriously affected. By signing below, I understand the nature and purposes of these procedure(s) and the risks involved, including being exposed to a small dose of radiation, and the possible consequences of not consenting to the procedure(s).

**If I am pregnant I will inform the technician and refuse to take x-rays.

I have read the above statement regarding Xrays*

Yes

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION.

By law, we are required to provide you with our Notice of Practice. Please sign below acknowledging your receipt of this information. This shall also serve as consent to use and/or disclose your protected health information to carry out treatment, payment activities, and health care operations. If you should have any questions regarding this Notice and consent, you may contact: Paige Orthodontics at 281-358-6580.

Patient, parents or legal Representative (electronic signature):*

First Last

Date*