Health History/HIPAA/Communication Authorization/Media Consent - HOS

HEALTH/DENTAL HISTORY

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Who may we thank for referring you?*

What helped you decide to come to Houston Orthodontic Specialists? (Check all that apply)

Friends Family Social Media Our Website Online Reviews Other

Other:

The following information is for a(n):*

Adult Child

Sex:*

Male Female

Patient's First Name:*

Patient's Last Name:*

Prefers to be addressed as:

Date of Birth:*

School Name:

Grade:

Email Address:

Home Phone #:

Cell Phone #:*

Cell Phone Carrier:

Is texting permitted?

Yes No

Home Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Does the patient have siblings?

Yes No

Sibling Name(1):

Sibling Age(1):

Sibling Name(2):

Sibling Age(2):

Sibling Name(3):

Sibling Age(3):

Sibling Name(4):

Sibling Age(4)

Employed by:

Occupation:

Work Phone:

Father's Information

Father/Partner Name:*

Father/Partner Occupation:

Father/Partner Work Phone:

Father/Partner Employer:

Father/Partner S.S.N:

Father/Partner Cell Number:

Mothers's Information

Mother/Partner Name:

Mother/Partner Occupation:

Mother/Partner Work Phone:

Mother/Partner Employer:

Mother/Partner S.S.N:

Mother/Partner Cell Number:

Marital Status:*

Single Married Divorced Separated Widowed

Parents' Marital Status:*

Single Married Divorced Separated Widowed

Guardian's Information

Guardian's Name:

Guardian Phone:

Guardian Cell:

Guardian's Employer:

Guardian's Occupation:

Guardian's Work Phone:

Spouse's Name:

Spouse Occupation:

Best Phone # to Be Reached:

Spouse's Employer

Person Responsible for Account:

Father Mother Guardian Other

Name of person responsible:

Person Responsible for Account:

Self Spouse Other

Name of person responsible:

Address of person responsible (if different from patient):

Business Phone:

Cell#

S.S.N:

Contact in case of Emergency (Name):

Phone:

Cell#:

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.*

Agree

Click here to read the HIPAA Consent Policy

Click here to review AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:

Person/Organization Name:

Address

Address Line 1

City

State

ZIP Code

Phone:

Fax:

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Person/Organization Name:

Address:

Address Line 1

City

State

ZIP Code

Phone:

Fax:

REASON FOR DISCLOSURE (Choose only option below)

Treatment/Continuing Medical Care Personal Use Billing or Claims Insurance Legal Purposes Disability Determination School Employment

WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.

Your initials are required to release the following information:

Mental Health Records (excluding psychotherapy notes)

Genetic Information (including Genetic Test Results)

Genetic Information (inclDrug, Alcohol, or Substance Abuse Recordsuding Genetic Test Results)

HIV/AIDS Test Results/Treatment

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional):

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

Signature of Individual or Individual’s Legally Authorized Representative

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Printed Name of Legally Authorized Representative (if applicable):

If representative, specify relationship to the individual:

Parent of Minor Guardian

Other:

A minor individual’s signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam. Code § 32.003).

Signature of Minor Individual

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Authorization for Cell Phone and Email Use

I acknowledge that I will receive email & text communications regarding treatment information, insurance, account and billing information, special promotions, and third party surveys. I understand that I can withdraw my consent at any time.

Agree

Certification:

I certify that I am the authorized representative for the patient. I certify that I am the patient

My relationship to the patient is:

Photographic / Media / Social Media Consent

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Houston Orthodontic Specialists and its affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).
I hereby consent to the collection and use of my personal images by photography or video recording.
I further acknowledge that Houston Orthodontic Specialists may use my image in media to promote the practice in the future.
I understand that no personal information, such as names, will be used in any publications unless express consent is given.
I also understand that my consent can be withdrawn at anytime in writing to Houston Orthodontic Specialists.

I have read the above statements and I give this consent voluntarily.*

Agree Do Not Agree

DENTAL INSURANCE

Do you have Dental Insurance?*

Yes No

Primary Dental Insurance Co:*

Policy Holder's Employer:*

SSN/Member ID:

Ortho Coverage:

Yes No

Policy Holder's Name:

Policy Holder's Phone #:

Policy Holder's Birthdate:

Do you have Secondary Insurance?

Yes No

Secondary Dental Insurance Co:

Policy Holder's Employer:

SSN/Member ID:

Ortho Coverage:

Yes No

Policy Holder's Name:

Policy Holder's Phone #:

Policy Holder's Birthdate:

YOUR DENTAL HISTORY

PATIENT DENTAL HISTORY

Do you have a Dentist?*

Yes No

Patient Dentist Name:

Date of Last Visit:

Have there been any injuries to the face, mouth or teeth?*

Yes No

Explain your injury:

Have you had or do you presently have any of the following habits?

Thumb or finger sucking Lip Biting Snoring Grinding of the teeth at night Mouth breathing Other

Other habits:

Have you been informed of any missing or extra permanent teeth?*

Yes No

Are you aware of sores, lumps or irritated areas in the mouth?*

Yes No

Has an orthodontist been consulted previously?*

Yes No

Orthodontist's Name:

Date:

Have you had previous orthodontist treatment?

Yes No

Type of treatment:

Have you ever been treated for:*

Bad Bite TMJ Periodontal disease None

Doctors Name:

Do you have bleeding gums?*

Yes No

Are you frightened or anxious about Orthodontic treatment?*

Yes No

Are you concerned about the appearance of your teeth?*

Yes No

Do you have any speech problems?*

Yes No

Is there anything you would like to change about your smile?*

Yes No

What would you like to change?

What aspect of dental treatment are you most concerned with?

Quality Cost Discomfort Time

Reason for consultation (chief concern):*

If patient is ready to start treatment, would you be able to start immediately?

Yes No

Has there ever been any orthodontic treatment for any other member of your family?

Child Spouse Other Family Member

Child's Doctor:

Stage of TX:

Were they satisfied with the results?

Yes No

Spouse's Doctor:

Stage of TX:

Were they satisfied with the results?

Yes No

YOUR MEDICAL HISTORY

PATIENT MEDICAL HISTORY

Is your general health good at this time?*

Yes No

Comments

Are you under the care of a physician at this time?*

Yes No

Explain

What is the name of your family physician?*

Date of last physical:

Are you taking any medication?*

Yes No

Medication Names:

Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)*

Yes No

List allergies:*

Have you ever had a serious illness or been hospitalized?*

Yes No

Explain your illness:

Have you had your tonsils and/or adenoids removed?*

Yes No

What Age?

Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?*

Yes No

Antibiotic name and method:

Pharmacy:

Do you have any special problems not listed?*

Yes No

Explain Problems:

Do you use tobacco?*

Yes No

Are you pregnant or considering pregnancy during the next 2 years?

Yes No

Have you ever been pregnant?

Yes No

Are you currently taking medication for birth control?

Yes No

Are you nursing?

Yes No

DO YOU HAVE NOW, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Heart Surgery Date:

Hepatitis Type:

List Other Medical Issues:

Handicap/Disabilities:

Notes:

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

Houston Orthodontic Specialists may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.

Signature

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DENTAL HISTORY - CHILD

DENTAL HISTORY - CHILD

Do they have a Dentist?*

Yes No

Patient Dentist Name:*

Date of Last Visit:

Have there been any injuries to the face, mouth or teeth?*

Yes No

Have they had or do they presently have any of the following habits?

Thumb or finger sucking Lip Biting Snoring Grinding of the teeth at night Mouth breathing

Have they been informed of any missing or extra permanent teeth?*

Yes No

Are you aware of sores, lumps or irritated areas in the mouth?*

Yes No

Has an orthodontist been consulted previously?*

Yes No

Orthodontist's Name:

Date:

Have they ever been treated for:*

Bad Bite TMJ Periodontal disease None

Doctors Name:

Are you frightened or anxious about Orthodontic treatment?*

Yes No

Are you concerned about the appearance of their teeth?*

Yes No

Do they have any speech problems?*

Yes No

Is there anything you would like to change about their smile?*

Yes No

What would you like to change?

What aspect of dental treatment are they most concerned with?*

Quality Cost Discomfort Time

Reason for consultation (chief concern):*

If patient is ready to start treatment, would you be able to start immediately?*

Yes No

MEDICAL HISTORY - CHILD

MEDICAL HISTORY - CHILD

Is their general health good at this time?*

Yes No

Comments

Are they under the care of a physician at this time?*

Yes No

Explain

What is the name of your family physician?

Date of last physical:

Are they taking any medication?*

Yes No

Medication Names:

Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)*

Yes No

List allergies:

Have they ever had a serious illness or been hospitalized?*

Yes No

Explain the illness:

Have they had their tonsils and/or adenoids removed?*

Yes No

What Age?

Do they have any special problems not listed?*

Yes No

Explain Problems:

Have they ever been advised by a physician to take an antibiotic prior to any dental treatments?

Yes No

Antibiotic name and method:

Pharmacy:

What is their approximate height?

What is their approximate weight?

Have you recently noticed a growth spurt?

Yes No

Have you had your first menstrual cycle?

Yes No

Date:

Has puberty been reached?

Yes No

DO THEY HAVE NOW, OR HAVE THEY EVER HAD ANY OF THE FOLLOWING?

Heart Surgery Date:

Hepatitis Type:

List Other Medical Issues:

Handicap/Disabilities:

Notes:

Signature

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