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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: Page 1 of 2 ________________________________________________________ (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: ______________________________________________________ Page 2 of 2