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Welcome To Our Office The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you. Patient Information Patient’s Name____________________________ Address__________________________________ City_________________State_____Zip________ Birthdate_____________SS#_________________ Home#_____________Cell #_________________ School____________________________________ Hobbies___________________________________ Email Address_____________________________ Dental Insurance Information Whom may we thank for referring you to our office? ________________________ Responsible Party Information Name_____________________________________ Address_________________________________ City__________________State______Zip_______ Home#______________Work#________________ Cell#_____________________________________ Birthdate_______________SS#________________ Relationship to Patient_______________________ Employer_______________Years Employed_____ Occupation________________________________ Email Address_____________________________ Spouse’s Name____________________________ Birthdate________________SS#_______________ Work#__________________Cell#______________ Employer_______________Years Employed_____ Occupation________________________________ Other family members seen by Dr Oliver_______ __________________________________________ Subscriber Name____________________________ Birthdate_______________SS#________________ Relationship to patient_______________________ Insurance Co.______________________________ Insurance Phone #___________________________ Do you have secondary coverage? Yes No If yes, please list coverage____________________ _________________________________________ Emergency Information Name of nearest relative not living with you __________________________________________ Address___________________________________ City_________________State_____Zip_________ Home#______________Work#________________ Dr. Brian Oliver Orthodontics for Children & Adults 5901 Grelot Road Building E Mobile, AL 36609 Tel 251-639-0801 Fax 251-461-0794 HEALTH HISTORY Medical History Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA. Your Dentist Physician’s Name _____________________________ Date of last Visit ______________________________ Current Medications____________________________ _____________________________________________ Allergies (including drugs, nickel, latex, etc.)________________ Previous/Present dentist______________________ _________________________________________ Date of last visit____________________________ ______________________________________________________ Have you ever had surgery or been hospitalized and why? _______ ______________________________________________________ Your current physical health is Good Fair Poor Does patient have a history of any of the following? Dental History Why have you come to the orthodontist today?____ __________________________________________ __________________________________________ Are you currently in pain? Yes No Your current dental health is Good Fair Poor Please check any of the following conditions that apply to patient: Y N Bleeding Gums Y N Grinding Teeth Y N Jaw/Joint Pain Y N Periodontal/Gum Treatment Y N Clicking/Popping Jaws Y N Cleft Palate Y N Tooth Sensitivity Y N Headaches Y N Anemia Y N Arthritis, rheumatism Y N Asthma Y N Blood Disease Y N Chemical Dependency Y N Chemotherapy/Cancer Y N Cough/Persistent Y N Diabetes Y N Epilepsy/fainting spells Y N Heart Problems/Murmur Y N Hepatitis Y N High Blood Pressure Y N Rheumatic/Scarlet Fever Y N Kidney Disease Y N Liver Disease Y N Mitral Valve Prolapse Y N Radiation Therapy Y N Shortness of Breath Y N Stroke/Heart Attack Y N Thyroid Problems Y N Tobacco Habit Y N Tuberculosis Y N Ulcer Y N Venereal Disease Y N HIV+/Aids Describe Heart Problems_____________________ _________________________________________ Does patient require pre-medication_____________ AUTHORIZATION I understand the above questions and have provided accurate answers to the best of my knowledge. It is my responsibility to inform this office of any changes in the patient’s medical status. I understand that providing incorrect information can be dangerous to the health of those individuals treating the patient. I understand that once a diagnosis and treatment plan has been developed, the fees and methods of payment will be discussed with me and a financial agreement will be established. I understand that, when appropriate, credit reports may be obtained. I also authorize the release of any information regarding diagnosis and the records of any treatment or examination rendered to the patient during orthodontic care to third party payers and/or health practitioners. I understand that my dental insurance may pay less than the actual amount owed for services. I agree to be responsible for payments of all services rendered on my or patient’s behalf. Name (please print)__________________________ Signature__________________________________ Relationship to patient____________Date________