Adult New Patient Information - Cook Orthodontics

Dr. Jeff Cook

Adult New Patient Information
Date

MonthDayYear
Patient Name

First NameMiddle NameLast Name
MaleFemaleNon-Binary
Social Security Number
Date of Birth

MonthDayYear
Age
SingleMarriedPartneredDivorcedWidowed
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Email
Employer
Position/Occupation
Business Phone
Format: (000) 000-0000.
Spouse/Partner

First NameMiddle NameLast NameNickname or perferred name
Employer
Position/Occupation
Business Phone
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Chief reason you are seeking treatment
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
Patient Account Information
YesNo
YesNo
Person(s) responsible for the account
Name
Relationship to patient
Social Security
Date of Birth

MonthDayYear
Email Address
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell
Format: (000) 000-0000.
Work
Format: (000) 000-0000.
Orthodontic Insurance Information
Insurance Company Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber (Insured) Name
Date of Birth

MonthDayYear
Relationship to Patient
Subscriber ID
Social Security#
SSN
Group
Employer Name
Secondary Insurance
Insurance Company Name
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber (Insured) Name
Date of Birth

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

MonthDayYear
What are the main concerns you would like orthodontics to accomplish?
YesNo
YesNo
Treatment Length?
YesNo
YesNo
YesNo
TeethMouthChin
YesNo
If so, explain
YesNo
YesNo
Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating ProblemsSnoring
Is all dental work complete?
Medical History
YesNo
YesNo
If yes, please list allergies
YesNo
Please list medications
YesNo
If yes, describe
Please Check all that apply
YesNo
YesNo
AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyChronic SinusCirculatory ProblemsConvulsionsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcer
Authorization
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
Patient Signature and/or Responsible Party

Clear
Date
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Section A: Patient 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
Section B: To The Patient - Please read the following statements carefully.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information carry our treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Yuma Main Office

Telephone: (928) 267-1697

E-mail: cookortho@mb2dental.com

Address: 2851 S. Avenue B #18, Yuma, AZ 85364

Gila Ridge Office

Telephone: (928) 267-1697

E-mail: cookortho@mb2dental.com

Address: 7945 E. 24th Street, Yuma, AZ 85365

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
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: blanks
Relationship to Patient: blanks 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
© 2023 Cook Orthodontics | All Rights Reserved.
Should be Empty:

Dr. Jeff Cook

Person(s) responsible for the account

Secondary Insurance

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION