Patient Information - AdultWe would like to welcome you to our office. To provide the best service possible, we ask you to fill out this form as completely as possible prior to your first appointment with us. Thank you for your cooperation. First Name*Last Name*Nickname (if preferred)Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleMailing Address*City*State*Zip Code*EmailCell Phone*Alternative PhoneEmergency Contact Name*Phone Number*Relationship*How did you hear about our office?*Have we treated another member of your family?*YesNoIf YES, Name (First, Last):Primary Insurance InformationInsurance Company NameGroup/Plan #Subscriber ID or SSNInsurance Company Phone #Insurance Company AddressInsured’s NameDate of Birth Date Format: MM slash DD slash YYYY Relation to PatientInsured’s EmployerEmployer’s AddressSecondary Insurance InformationInsurance Company NameGroup/Plan #Subscriber ID or SSNInsurance Company Phone #Insurance Company AddressInsured’s NameDate of Birth Date Format: MM slash DD slash YYYY Relation to PatientInsured’s EmployerEmployer’s AddressPatient Medical HistoryAre you currently under the care of a physician?*YesNoIf YES, for what reason?PhysicianPhoneHistory of major illness?*YesNoIf YES, please describe:Currently taking any medication?*YesNoIf YES, please list:Allergic to any medications?*YesNoIf YES, please list:Are you LATEX sensitive?*YesNoAre you currently taking or have been given oral or intravenous Biophosphates (i.e. Fosamax, Actonel, Boniva)?*YesNoHave tonsils and/or adenoids been removed?*YesNoDo you use any tobacco products?*YesNoIf female, are you pregnant?YesNoHave you been treated for any of the following? Allergies Arthritis Asthma Blood/Bleeding Disorder High Blood Pressure Cancer Diabetes Epilepsy Tuberculosis Heart Conditions Hepatitis HIV/AIDS Headaches Nervous Disorder Rheumatic Fever Are there any medical conditions we have not discussed that we should be aware of?Dental HistoryDentist*Date of Last Visit Date Format: MM slash DD slash YYYY Do you require antibiotics before dental treatment?*YesNoIf YES, explain:Have you ever had pain/tenderness/clicking/popping in your jaw joint (TMJ/TMD)?YesNoHave there been injuries to your face, mouth or chin?YesNoHave you had previous orthodontic treatment?YesNoIf YES, why?What are the main concerns that you would like orthodontics to address?SignatureI understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in medical status. I consent to examination by the doctor. I hereby authorize release of any information related to insurance claims and I authorize payment of any insurance benefits. Sign Name Here*Date Date Format: MM slash DD slash YYYY HIPAA NOTICE OF PRIVACY PRACTICESThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully, and ask any questions you may have.We will ask you to sign the back of this form prior to starting any treatment. Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects: 1. To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.); 2. To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.); 3. To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, State dental boards, etc.) in connection with obtaining certification, licensure or accreditation; 4. Internally, to all staff members who have any role in your treatment; 5. To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.; 6. To your family and close friends involved in you treatment; and/or; 7. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses or disclosures of you protected health information will be made only after obtaining your written authorization, which you have the right to revoke. Under the new privacy rules, you have the right to: 1. Request restrictions on the use and disclosure of your protected health information; 2. Request confidential communication of your protected health information; 3. Inspect and obtain copies of your protected health information through asking us; 4. Amend or modify your protected health information in certain circumstances; 5. Receive an accounting of certain disclosures made by us of your protected health information; and,You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation). We have the following duties under the privacy rules: 1. By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information; 2. To abide by the terms of our Privacy Notice that is currently in effect; and, 3. To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice. Please note that we are not obligated to: 1. Honor any request by you to restrict the use or disclosure of your protected health information; 2. Amend your protected health information if, for example, it is accurate and complete; or, 3. Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties. This privacy notice is effective as of the date of submitting this form. If you have any questions about the information in this Notice, please ask Dr. Ana Castilla prior to submitting. Thank you.PATIENT ACKNOWLEDGEMENT*YesI acknowledge that I have received a copy of this office’s Notice of Privacy Practices Sign Name Here*Date* Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.