Download Patient INFORMATION - Commonwealth Orthodontics

For Office
Use:
Ins:_______________
6657 Lake Harbour Drive
Midlothian, VA 23112
(804) 739-6600
JEFFREY W. BEYER, DDS
Specialist in Orthodontics
and
Dentofacial Orthopedics
 Ph1  Full
 Recs
 Upper
 Trans Start
 Rets Only
456 CH Dimmock Pkwy. Ste.9
Colonial Heights, VA 23834
(804) 520-7292
 RME
 Invs
 Upr/Lower
 DB Only
 Recall
Tx:_______________
Mo: _______________
PATIENT INFORMATION
Patient Name:
Patient DOB:
Date:
Patient Full Address:
City & Zip:
Cellular
Number:
Cellular Carrier:
Email :
Preferred Contact Method: ☐ Cellular ☐ Email ☐ Both
☐ Other:_________________________________________________
Dentist or dental practice name:
When was your last dental cleaning/check-up?
Do you have any pending dental work that needs to be
completed?
 Dentist
How were you referred to our practice:
 Yes
 Insurance
 No
 Internet
 Friend
 Advertisement
(Name):____________________________
(Where):________________________
 Google+  Facebook
 Location/Drive
By

Other:_____________________
Please briefly describe your reason(s) for today’s visit:
Is this your first visit to an Orthodontist?
 Yes  No
Have you worn braces before?
 Yes  No
Do you take any Bisphosphonates?
 Yes  No
Are you allergic to nickel?
 Yes  No
Are you under the care of a physician?
 Yes  No If yes, why?
Are you allergic to any medications or
latex?
 Yes  No If yes, which ones:
Are you taking any medications?
 Yes  No If yes, type and dose:
Female Patients ONLY:
Have you begun having your menstrual
cycles?
 Yes  No
Are you pregnant?  Yes
 No
DO YOU HAVE OR HAVE HAD THE FOLLOWING:
Liver disease, hepatitis or diabetes?
 Yes
 No
Problems with the temporomandibular joint (TMJ)?
 Yes  No
Epilepsy or other seizures?
 Yes
 No
Heart disease, murmur or rheumatic fever?
 Yes  No
Asthma or other breathing problems?  Yes
 No
Bleeding problems?
 Yes  No
 Yes
 No
Immunosuppressant disorders?
 Yes  No
Injury to the teeth or jaws?
If you answered YES to any of the above, or have any other conditions we should be aware of, please briefly describe them here:
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________________________________________________________
(Printed name of person completing this form)
__________________________________________
(Relationship to patient)
COMMONWEALTH ORTHODONTICS
CONSENT FOR OBTAINING, USE AND DISCLOSUREOF HEALTH INFORMATION
PATIENT NAME: _______________________________________________________________
SECTION A: CONSENT FOR EXAMINATION AND DIAGNOSTIC RECORDS
I hereby give my consent for Commonwealth Orthodontics to perform any and all necessary diagnostic orthodontic records including but
not limited to: intraoral/extraoral examination, digital photographs, impressions of the teeth, digital x-rays and a medical/dental history
review. I understand that any fees paid for these services are non-refundable, and all records are the property of Commonwealth
Orthodontics. I also understand that I may request that these records be transmitted electronically and/or duplicated and given to me or
another party. Once transmitted/released, I understand that Commonwealth Orthodontics has no further responsibility for any other
release by the individual(s) receiving this information.
Signature____________________________________________________________________Date____________________________
SECTION B: TO THE PATIENT OR LEGAL GUARDIAN—PLEASE READ CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out
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 Notice of 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 at any time by contacting the privacy officer at Commonwealth Orthodontics at
[email protected] or via phone (804) 520-7292 (Colonial Heights) or (804) 739-6600 (Midlothian).
Right to Revoke: You 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 to treat you if you revoke this consent.
ACKNOWLEDGEMENT OF CONSENT
I, _________________________________________ 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 out treatment, payment activities and healthcare operations.
Signature_____________________________________________________
Date_____________________________
If this consent is signed by a personal representative on behalf of the patient, complete the following:
Relationship to Patient: ______________________________________________________
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