Child New Patient Information- Cook Orthodontics

Dr. Jeff Cook

Child New Patient Information
Date

MonthDayYear
Patient Name

First NameMiddle NameLast Name
MaleFemaleNon-Binary
Preferred Pronoun
Date of Birth

MonthDayYear
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number
Format: (000) 000-0000.
Both Parents50/50
MomDadGrand Parents
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
SingleMarriedDivorcedPartneredWidowed
MotherFatherGuardian
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
SingleMarriedDivorcedPartneredWidowed
MotherFatherGuardian
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?
YesNo
YesNo
YesNo
YesNo
TeethMouthChin
YesNo
If so, explain
Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating ProblemsTongue Thrust
Medical History
YesNo
YesNo
Physician Name
If yes, please list allergies
YesNo
Please list medications
YesNoN/A
Has your child had any serious illnesses or operations? If yes, describe
YesNo
If yes, give approximate dates

MonthDayYear
AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyChronic SinusCirculatory ProblemsConvulsionsCough, PersistentDiabetesEmotional DisorderEpilepsyFaintingHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLearning DisabilityLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcer
YesNo
FatherMotherNeither
YesNo
Height of Patient
List any musical instruments played
YesNo
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
Hello Team,

You have received a new patient form submission - Child.

Thanks

MB2 Dental

{pdf-link}
Should be Empty:

Dr. Jeff Cook

Primary Responsible Party

Secondary Responsible Party

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION