New Patients

Patient Type

Adult

Child

ADULT PATIENT INFORMATION & HISTORY

CHILD PATIENT INFORMATION & HISTORY

Patient’s Full Name *

Date of Birth *

Age

Home Address

Home Phone

City *

State *

Zip Code *

Parent #1 Name *

Cell phone *

E-mail

Same Address as Patient?

Yes

No

Parent #2 Name

Cell phone

E-mail

Same Address as Patient?

Yes

No

Other Guardian’s Name

Relation

Cell phone

Same Address as Patient?

Yes

No

Mobile Phone Number *

Home Number

E-mail *

Spouse’s Name

Same Home Address as Patient

Yes

No

Phone Number

E-mail

Billing Party’s Name *

Relation *

Billing Party’s Date of Birth *

E-mail *

If address differs from patient, please provide here

Who May We Thank for Referring you? *

HEALTH CARE PROFESSIONALS

Dentist's Name *

Phone Number

Address

Physician's Name *

Phone Number

Address

PRIMARY - DENTAL INSURANCE INFORMATION

Name of Policy Holder

Relation to the Patient

Date of Birth

Social Security Number

Employer

Employer's Address

Insurance Company

Ins Phone Number

Ins Address

Payor ID

Member ID or SSN

Group Number

SECONDARY - DENTAL INSURANCE INFORMATION

Name of Policy Holder

Relation to the Patient

Date of Birth

Social Security Number

Employer

Employer's Address

Insurance Company

Ins Phone Number

Ins Address

Payor ID

Member ID or SSN

Group Number

HEALTH HISTORY

Is the patient currently under medical treatment? *

For What? *

Is the patient currently taking any medication? *

For What? *

List all medications patient is taking *

List anything patient is allergic to *

Is the patient currently in pain? *

Where? *

Has the patient ever had a reaction to jewelry? *

Has your child shown signs of puberty and/or had their first menstrual cycle? If so, about how long ago? *

DENTAL HISTORY

Has the patient ever had previous orthodontic consultation? *

Where? *

Has the patient ever been previously treated by an orthodontist? *

Where? *

What are your primary concerns for this visit (crowding, over/underbite, gaps, etc.)? *

What are your/your child’s primary concerns for this visit (crowding, over/underbite, gaps, etc.)? *

Are there any parts of your smile that you want to be improved? *

Are there any parts of your child’s smile that you or they want to be improved? *

Do you have any concerns about orthodontic treatment? *

Do you or your child have any concerns about orthodontic treatment? *

If injury to teeth, mouth or jaw occurred, what happened and when? *

Any other conditions or issues we should be aware of? *

I certify that the answers I provided on this form, including the answers to these health questions are correct to the best of my knowledge. I grant authority to the Orthodontist(s) and staff to perform all procedures and treatments that are necessary. I grant permission to use clinical photos, x-rays, models, etc. for educational and social media purposes. I understand that, where appropriate, credit bureau reports may be obtained.

Parent/Guardian’s name *

Signature *

Date *

AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION BY EMAIL AND OTHER ELECTRONIC MEANS

Unless I provide written notice, I authorize Dr. J. B. Peterman to transmit patient information relating to my treatment, health, or payment by email or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and others involved in my treatment, payment for my treatment, or Dr. J.B. Peterman’s health care operations. The patient information emailed may include x-rays, health history, diagnosis, treatment and payment records.

I understand that:

I do not have to sign this form
My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form.
If I don’t sign this form, Dr. J. B. Peterman may use other ways to send my information, such as U.S. mail, or may ask me to pick up and send my information to third parties myself.
There is some risk that e-mails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be redisclosed and no longer protected by practice law.
Dr. J. B. Peterman does not email such sensitive personal information as Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/ substance abuse, or positive HIV status unless the patient insists.

I understand that I can provide written request to stop emailing my patient information at any time, but if I do so, this will not affect emails that Dr. J. B. Peterman already sent before receiving my written instructions to stop.

Patient Name *

Guardian Name *

Signature *

Guardian Signature *

Date *

NOTICE OF PRIVACY PRACTICES

This notice describes how medical/dental information about a patient may be used and disclosed. Please read carefully.

Protected Health Information (PHI) is information that may identify you and that relates to your past, present or future physical or mental health or conditions and related health-care services. This notice of privacy practices describes a patient’s rights and how the office of J. B. Peterman D.M.D. may use and disclose PHI to carry out treatment, payment (insurance submission), health care operations, and for other purposes permitted or required by law.

J. B. Peterman D.M.D. will not use or disclosure PHI about a patient without your or a legal guardian’s written permission, except as described in this notice. We are required by law to maintain the privacy of PHI and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. We are also required to abide by the terms of this notice of privacy practices. We may change our practices and this notice, and make the new notice effective for the PHI we maintain. If you request it, we will provide you with a revised notice.

Your Rights:
You may obtain a paper copy of this Notice of Privacy Practices upon request at any time.

You may inspect and obtain a copy of your PHI, which usually includes patient information, course of treatment, x-rays, and billing information. We may charge you for copying and mailing, and any supplies needed to fulfill your request. We may deny your request in certain instances, and you may ask to have your denial reviewed.

You may request a change to your PHI. If you review your PHI and find information incomplete or incorrect, you may request an amendment to it for as long as we maintain your PHI. You may request a restriction of your PHI. This means that you may ask us not to disclose or use any part of your PHI for purposes of treatment, payment, or healthcare operations. You may also request that your PHI not to be disclosed to certain family members, legal guardians, or friends who may be involved in your care. You must list the individuals to whom you want the restrictions to apply. We are not required to agree to a requested restriction.

How we may use and disclose PHI:

For treatment purposes including, but not limited to: treatment planning; healthcare operations; health-related communications to individuals involved in your care or payment for your care.

For payment and insurance information.

For public safety related operations including, but not limited to: the FDA; worker’s compensation; public health or disease control; law enforcement officials; coroners, medical examiners, and funeral directors; correctional facilities; military authorities; issues of National security; or victims of abuse, neglect, or domestic violence.

Please notify the office of J. B. Peterman D.M.D. if you have any questions related to this notice.

I have received a copy of this notice.

Additional Disclosure Authority:

In addition to the allowable disclosures described above, I hereby specifically authorize the disclosure of my PHI to the persons indicated below:

ANY MEMBER OF MY IMMEDIATE FAMILY *

Yes

No

SPOUSE ONLY *

Yes

No

Other (grandparents, baby sitters/nannies, aunts/uncles, etc) *

Patient Name *

Guardian Name *

Signature *

Patient Signature *

Date *

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.

ADULT PATIENT INFORMATION & HISTORY

CHILD PATIENT INFORMATION & HISTORY

HEALTH CARE PROFESSIONALS

PRIMARY - DENTAL INSURANCE INFORMATION

SECONDARY - DENTAL INSURANCE INFORMATION

HEALTH HISTORY

DENTAL HISTORY

AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION BY EMAIL AND OTHER ELECTRONIC MEANS

NOTICE OF PRIVACY PRACTICES

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