BCO - Current Patient -Update Patient Information / Medical History

Current Patient - Updated Patient Information

(CONFIDENTIAL)
Full Name *

First Name Last Name
Gender *
Birth Date *

Month Day Year
Age
Phone Number *

- Area Code Phone Number
Contact E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

School Name
If patient is a student
City
Grade/Year
Emergency Contact *

First Name Last Name
Phone Number *

- Area Code Phone Number
Family Dentist's Name (If you don't have a dentist please insert N/A) *

First Name Last Name
Phone Number

- Area Code Phone Number
Family Physician's Name

First Name Last Name
If patient is a minor, please provide the following:
Father's Name
Father's Contact Number
Father's Email Address
Mother's Name
Mother's Contact Number
Mother's Email Address
Check the Appropriate Box

Single Married Divorced Widowed Seperated
Responsible Party #1

If covered by dental insurance, subscriber is primary responsible party. Additional financial responsible party should be added below as #2.
Name of the person responsible for this account *

First Name Last Name
Birth Date *

Month Day Year
Relationship to patient *
Social Security Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
Employer
Have Orthodontic Insurance?

Yes No
Name of Dental Insurance Company
Subscriber ID (or SS#)
Responsible Party #2

Allows financial information access to listed person
Name of the person responsible for this account

First Name Last Name
Birth Date

Month Day Year
Relationship to patient
Social Security Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
Employer
Have Orthodontic Insurance?

Yes No
Name of Dental Insurance Company
Subscriber ID (or SS#)
Update Medical History
Patient's General Health *

Excellent Good Fair Poor
Previous Hospitalizations/Surgeries/Serious Illnesses
Is patient under a physician's care at present? *

Yes No
If yes, reason.
Is patient currently taking any medication? *

Yes No
If yes, describe.
Does patient need to be pre-medicated? *

Yes No
If yes, describe.
Has patient ever had any of the following?

Has the patient ever had any of the following: *

	Yes	No
Asthma
Cancer
Hepatitis
HIV/AIDS
Hemophilia
Abnormal Bleeding
Handicaps/Disabilities
Tuberculosis
Diabetes
Heart Murmur
Allergy
Convulsion/Epilepsy
Congenital Heart Defect
Stomach/Liver or Kidney Problems
Metal Allergy

If yes, describe
Please list any other significant information about the patient's medical history
Updated Dental History
Last Dental Check-Up Date

Month Day Year
By Dr.
How often do you brush your teeth? *
How often do you floss your teeth? *
Bleeding? *

Yes No
Does the patient gag easily? *
Has the patient had any previous orthodontic treatment? *
If yes, when?
Has the patient had any previous injuries to mouth, jaw or teeth? *
If yes, when?
Has the patient had any pain in jaw joints? *
If yes, when?
Does the patient have any of the following habits?
Finger/Thumb Sucking? *

Yes No
Tongue Thrust Habit *

Yes No
Clinching or Grinding of Teeth *

Yes No
If yes to any above, please provide details. Any other Mouth Habits?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to the patient’s health. It is my responsibility to inform Dr. Lee of any changes in medical and/or dental status. I also authorize Dr. Lee, and staff to perform all the necessary procedures deemed appropriate to make a thorough diagnosis of the patient’s dental and oral facial needs.
Please Sign/ Legal Guardian (If Patient is under 18) *

Clear
HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
Today's Date

- Month - Day Year
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy of Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITYS IN THE FUTURE.
Please print patient's name *
Legal Representative
Description of Authority
Please Sign/ Legal Guardian (If Patient is under 18) *

Clear
Your comments regarding Acknowledgements or Consents:
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step parents, grandparents and any caretakers who can have access to this patient's records):
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:
Please check all that apply *

Any form as needed Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
Please check all that apply *

Any form as needed Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO ON BEHALF OF THIS HEALTHCARE FACILITY VIA:
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
Should be Empty:

Current Patient - Updated Patient Information

Responsible Party #1

Responsible Party #2

Update Medical History

Has patient ever had any of the following?

Updated Dental History

HIPAA OMNIBUS RULE