Please complete this information form to help us become better acquainted Creating Beautiful Healthy Smiles For Life! and to be able to offer you the best possible care. PATIENT INFORMATION DATE _________________ AGE _______________ NAME OF SCHOOL (child)_________________________________________________________________ PATIENT’S NAME _________________________________________________________ BIRTHDAY _____/_____/_____ MALE FEMALE Last First MI D M Y ADDRESS _____________________________________________________ CITY ____________________________________ PROV __________ PC ____________ HOME PHONE________________________________________________ DENTIST’S NAME ________________________________________________________ CELL PHONE _________________________________________________ OCCUPATION ____________________________________________________________ WORK PHONE _______________________________________________ Whom may we thank for referring you? E-MAIL ________________________________________________________ Dentist Friend Family Website Other FAMILY MEMBERS SEEN BY US _____________________________________________________________ PARENT INFORMATION (please complete if patient is under the age of 18) PATIENT LIVES WITH: MOTHER FATHER BOTH PARENTS OTHER (please specify) __________________________ PERSON RESPONSIBLE FOR THE ACCOUNT ____________________________________ RELATION _________________________________________ ADDRESS (if different from the patient) _________________________________________________________________________________________________ CITY ________________________________________ PROV ________________ PC ________________ HOME PHONE _____________________________ CELL PHONE ________________________________ WORK PHONE ____________________________ MOTHER’S INFORMATION FATHER’S INFORMATION NAME ______________________________________________________ NAME ____________________________________________________________ ADDRESS __________________________________________________ ADDRESS ________________________________________________________ (if different from patient) (if different from patient) OCCUPATION _____________________________________________ OCCUPATION ___________________________________________________ HOME PHONE ____________________________________________ HOME PHONE __________________________________________________ WORK PHONE ____________________________________________ WORK PHONE _________________________________________________ CELL PHONE ______________________________________________ CELL PHONE ___________________________________________________ E-MAIL _____________________________________________________ E-MAIL __________________________________________________________ INSURANCE Our office charges the patient/parent/guardian directly for all professional services rendered. We will assist you in completing the necessary claim forms, so that you can receive the reimbursement to which you are entitled under your policy. DO YOU HAVE ORTHODONTIC COVERAGE? YES NO UNSURE NAME OF INSURANCE COMPANY: ____________________________________________________________ POLICY #: _________________________________________ ID # ________________________________________ SUBSCRIBER’S NAME __________________________________________________________________________ SUBSCRIBER’S BIRTHDAY _____________________________________________________________________ DO YOU RECEIVE FUNDING THROUGH: Indian Affairs Social Assistance A.I.S.H. Ward of Government Cleft Palate Clinic
DENTAL HISTORY Reason for consultation (chief concern) ________________________________________________________________________________________________ Is the patient happy with his/her smile? Yes No If not, what would he/she change? ______________________________________________________________________________________________________ Has the patient ever had or been evaluated for orthodontic treatment? Yes No If yes, when? _____________________ Does the patient want treatment? Yes No Has the patient ever experienced problems with their jaws (TMJ) Yes No If yes, please specify ______________________________________________________________________________________________________________________ Have there been any injuries to the face, mouth, teeth, chin? Yes No If yes, please explain ______________________________________________________________________________________________________________________ Has the patient had or presently have any of the following habits: Thumb/ finger sucking Lip Biting Snoring Grinding Clenching Chronic Mouth Breathing Speech Problems Tongue Thrusting Chewing/Eating Problems Sinus Problems Nail Biting Does the patient see dentist regularly? Yes No How often does patient brush? _________________________________ How often does patient floss?____________________________________ MEDICAL HISTORY Physician’s Name _________________________________________________ Physician’s Phone No. _____________________________________________ Patient’s current health is Good Fair Is the patient currently under care of a Physician? Yes No If yes, please explain ______________________________________________________________________________________________________________________ Does the patient require antibiotics before dental treatment? Yes No If yes, please explain _________________________ Is the patient taking any prescription/over the counter drugs? Yes No If yes, please list all _______________________________________________________________________________________________________________________ Does the patient have any allergies? Yes No If yes, please list all _______________________________________________________________________________________________________________________ Do you use tobacco (smoking or chewing)? Yes No For females: Has the patient started her menstrual cycle ? Yes No Unsure For females: Is the patient pregnant? Yes No Unsure DOES THE PATIENT HAVE NOW, OR EVER HAD ANY OF THE FOLLOWING? (please check any that apply) YES YES YES Anemia/Blood transfusion Congenital heart defect High Blood Pressure Hemophilia Mitral Valve Prolapse Low Blood Pressure AIDS/HIV Pacemaker/Heart Attack/Stroke Hospitalized for any reason Alcohol/Drug Abuse Diabetes Kidney Problems Arthritis Emotional/Psychiatric Problems Liver Disease Artificial joints Emphysema Lupus Asthma Epilepsy/Seizures/Fainting Shingles Cancer/Chemotherapy Fetal Alcohol Syndrome Thyroid Problems Radiation Treatment Frequent Headaches Tuberculosis Colitis/Crohns Hay Fever Ulcers Hepatitis (type__________) Herpes (cold sores) If yes to any above, please explain _______________________________________________________________________________________________________ Describe any other medical conditions not listed ______________________________________________________________________________________ SIGNATURE I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. _________________________________________________________________ ____________________________________________ SIGNATURE PATIENT/PARENT/GUARDIAN DATE
Personal Information Consent Form We are committed to protecting the privacy of our patients’ personal information and to utilizing this information in a professional manner and in accordance with personal information protection laws (PIPEDA). Personal Information Collected Names, home addresses, work addresses, home/work/cell telephone numbers, email addresses Financial information: third party dental provider information; credit card information (encrypted) Pertinent medical and dental history Current clinical orthodontic findings How This Information is Used: To initiate and update patient files and to contact patients for subsequent visits and re-assessments To provide information required to process claims by third-party health benefit providers To process credit card payments and generate receipts – all credit card information is encrypted Medical and dental information is used to provide accurate diagnosis and treatment plan Personal Information is Disclosed to: Referring dentists and other dentists and dental specialists involved in patient’s treatment To third party dental providers for reimbursement of dental services To other health care professional if being consulted To legal firms or other parties with the consent of the patient only To the Alberta Dental Association and College if they were to review or inspect our office records or to interview our staff To prospective associates, partners and/or qualified purchasers who wish to review the practice as part of the due diligence process Professional Presentations and Publication: The diagnosis, treatment planning, treatment protocol and treatment result may be used for presentation to Professional Organizations and Publication in Professional Journals. Personal information such as name and contact information are not disclosed. Consent I have reviewed the above information and I consent to the collection, use, and disclosure of the personal information as set out above for Ilias Iype. I also pledge to respect the privacy of other patients in our office. ___________________________________ Responsible Party Signature Date
1. Does my policy have orthodontic coverage? 2. What is the benefit amount? 3. At what percentage are payments reimbursed? 4. Are there any conditions or restrictions? 5. How will the reimbursements be paid? 6. How do I submit claims? 7. Am I eligible for a lump sum claim if I pay in full? Unlike your dentist’s office, software does not exist for orthodontic offices to access or bill your insurance. All questions relating to coverage must be made by the policy holder to the insurance provider directly. Orthodontists are required to submit a CAO Standard Information Form to all insurance providers, detailing treatment and cost. (This form is often referred to as a pre-authorization, pre- determination and/or treatment plan.) Most insurance providers will not directly communicate with our office. Everything submitted to your insurance provider by our office is MAILED. Form processing can take approximately 1 week for local providers and approximately 3 weeks for out of town providers. We will gladly provide ALL claim forms and receipts necessary for your reimbursements. Coordination of Benefits occurs when there is more than 1 insurance provider: o The primary policy is the policy that belongs to the person whose birthday comes first in the year o Claims are made to both policies, one at a time o You must attach proof of payment from the 1 st policy when claiming to the 2 nd policy o Only 1 claim is needed for 2 policies within the same insurance provider Submitting your own claims through your insurance provider’s website or app will undoubtedly result in your reimbursements being processed faster than if we mail them.