• HEALTH/DENTAL HISTORY

  • What helped you decide to come to Compton Orthodontics?
  • The following information is for a(n):*
  • Sex:
  • Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is texting permitted?
  • Marital Status:*
  • Do you have children?*
  • Person Responsible for Account:*
  • Parents' Marital Status:*
  • Are there other children in the Family?*
  • Person Responsible for Account:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • HIPAA Consent

  • Click here to read the HIPAA Consent Policy

  • Authorization for Cell Phone and Email UseHIPAA Consent

  • I give my consent to the orthodontic practice to use my cell phone for appointments, treatment information, insurance, account and billing information and special promotions. I understand that I can withdraw my consent at any time.
     

  • Choose one or both:*
  • Certification:

  • Photographic / Media / Social Media Consent

    • Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Compton Orthodontics and its 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 Compton Orthodontics 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    • I also understand that my consent can be withdrawn at anytime in writing to Compton Orthodontics.
  • I have read the above statements and I give this consent voluntarily.*

  • DENTAL INSURANCE

  • Do you have Dental Insurance?*
  • Birthdate
     - -
  • Are you the Policy Holder?*
  • Birthdate
     - -
  • Do you have Secondary Insurance?
  • Birthdate
     - -

  • YOUR DENTAL HISTORY

  • Date of Last Visit:
     - -
  • Have there been any injuries to the face, mouth or teeth?*
  • Have you had or do you presently have any of the following habits?*
  • Have you been informed of any missing or extra permanent teeth?*
  • Are you aware of sores, lumps or irritated areas in the mouth?*
  • Has an orthodontist been consulted previously?*
  • Date
     - -
  • Do you have bleeding gums?*
  • Are you frightened or anxious about Orthodontic treatment?*
  • Are you concerned about the appearance of your teeth?*
  • Do you have any speech problems?*
  • Is there anything you would like to change about your smile?*
  • Has there ever been any orthodontic treatment for any other member of your family?
  • Were they satisfied with the results?

  • YOUR MEDICAL HISTORY

  • Is your general health good at this time?*
  • Are you under the care of a physician at this time?*
  • Date of last physical:
     - -
  • Are you taking any medication?**
  • Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)*
  • Have you ever taken any diet medication (Fen-Phen)?*
  • Have you ever had a serious illness or been hospitalized?*
  • Have you had your tonsils and/or adenoids removed?*
  • Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?*

  • YOUR MEDICAL HISTORY CONT.

  • Do you use tobacco?*

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

  • Please check if YES or leave unchecked for NO:

  • 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.

    Compton Orthodontics 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.

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