Child New Patient Information- Toombs Orthodontics

Kelly H. Toombs, D.D.S., P.A.

Child Patient Information
Date

MonthDayYear
Patient Name

First NameMiddle NameLast Name
Gender
Preferred Pronoun
Date of Birth

MonthDayYear
Age
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number
Format: (000) 000-0000.
Patient Resides with
Both Parents
Mother
Father
Grandparent(s)
Other Guardian(s)
Sole Custody
Siblings (names and ages)
School
Grade
Has another Orthodontist been consulted previously?
Date

MonthDayYear
Name Of Orthodontist
Please List any relatives treated in our office
How did you select our Office?
Person Referring
Parent/Guardian Information
Primary Responsible Party
Parent's Marital Status
Patient Relation
Name

First NameLast Name
Address (if different than child's)

Street Address

Street Address Line 2

CityState

Zip Code
Date Of Birth

MonthDayYear
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
Employer
Position/Occupation
Secondary Responsible Party
Parent's Marital Status
Patient Relation
Name

First NameLast Name
Address (if different than child's)

Street Address

Street Address Line 2

CityState

Zip Code
Date Of Birth

MonthDayYear
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
Employer
Position/Occupation
Orthodontic Insurance Information
Patient Name

First NameLast Name
Primary Insurance Company Name
Insurance Claims Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Phone Number
Format: (000) 000-0000.
Subscriber (Insured) Name
Date of Birth

MonthDayYear
Social Security
Relationship to Patient
Subscriber ID
Group#
Employer Name
Secondary Insurance Company Name
Insurance Claims Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Phone Number
Format: (000) 000-0000.
Subscriber (Insured) Name
Date of Birth

MonthDayYear
Social Security
Relationship to Patient
Subscriber ID
Group
Employer Name
Dental History
General Dentist
Last Visit

MonthDayYear
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child you have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
If so, explain
Does your child currently or has your child ever had any of the following habits?
Medical History
Is your child currently being treated by a physician?
Does your child have any allergies/sensitivities to medications or latex?
Physician Name
If yes, please list allergies
Is your child currently taking any prescription or over-the-counter medications?
Please list medications
Has puberty and/or menstruation begun?
Has your child had any serious illnesses or operations? If yes, describe
Has your child ever had a blood transfusion?
If yes, give approximate dates

MonthDayYear
Check if your child has or ever had any of the following:
Did Parent have Orthodontic Treatment
Face and mouth most resemble
Brother or sister or treated with Orthodontics
Height of Patient
List any musical instruments played
Is Patient active in sports?
List
Authorization
I understand that it is my obligation to inform this office of any changes in the patient's current medical/dental conditions as they develop.
Signature

Clear
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Section A: Person giving consent
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Telephone
Format: (000) 000-0000.
Email
Patient
Social Security Number
Signature

Clear
I, Type a label have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities and health care operations.
Signature: Signature Date: Date If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name: Type a label
Relationship to Patient: Type a label YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOUR SIGN IT. Include completed consent in the patient’s chart.
REVOCATION OF CONSENT
I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.
Signature: Signature Date: Date
Should be Empty:

Kelly H. Toombs, D.D.S., P.A.

Primary Responsible Party

Secondary Responsible Party

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION