BAO
Dr. Kim
Services
Bay Area Orthodontics Patient Care
Emergency
Contact Us
(408) 715-2712
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Step
1
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Patient Name
*
First
Last
Preferred Name or Nick Name
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient's Primary Residence
Resides - Full Time
Resides - Part Time
SSN#
Age
*
Birth Date
*
Gender
Male
Female
Other
Email
*
Cell Phone #
*
Alt Phone #
Has the Patient Ever Been Seen in Any of Our Offices Before?
Yes
No
Which Office Have They Been to Before?
Morgan Hill
Santa Clara
Sunnyvale
Does the Patient Have a Sibling That Has Been Seen In Our Office(s) Before?
Yes
No
Which Office Has the Sibling Been Seen at Before?
Morgan Hill
Santa Clara
Sunnyvale
Where Did You Hear About Us?
Family/Friend Referral
Doctor Referral
Internet Search
Event
Insurance Provider
Other
Name of Referrer
Primary Responsible Person
*
First
Last
Primary Person Date of Birth
SSH#
Primary Person Cell Number
Primary Person Alternative Number
Primary Person Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Responsible Person Relation to Patient
Biological Parent
Step-Parent
Other
Please Describe Relation to Patient
*
Secondary Responsible Person
*
First
Last
Date of Birth for Secondary Responsible Person
SSH# of Secondary Responsible Person
Cell Phone Number of Secondary Responsible Person
Secondary Responsible Person Alternative Phone
Address of Secondary Responsible Person
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Secondary Responsible Person Relation to Patient
Biological Parent
Step-Parent
Other
Describe Secondary Responsible Person Relation to Patient
Email
Next
Insured's Name:
*
First
Last
Date of Birth
*
Gender
Male
Female
Other
Insured's Relation to Patient
Biological Parent
Step-Parent
Self
Other
Insured Relation to Patient if Other
*
Insured's Home Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Insured's SSN#
Employer
Employer's Phone #
Group #
Policy Number
Policy Effective Date
Union Name and Local Union #
Next
Emergency Contact 1 Name
*
First
Last
Relationship to Patient
*
Parent
Step Parent
Self
Other
Emergency Contact Relationship to Patient if Other
*
Cell Phone #
*
Alternative Emergency Contact Phone #
Emergency Contact 2 Name
*
First
Last
Emergency Contact 2 Relationship to Patient
Biological Parent
Step Parent
Self
Other
Emergency Contact 2 Relationship to Patient if Other
*
Emergency Contact 2 Phone #
Emergency Contact 2 Alternative #
Next
Photo Consent
*
Yes
No
I authorize Bay Area Orthodontics to post images and/or videos of the patient on their website and social media for promotional and marketing purposes. I also understand that I reserve the right to revoke this authorization in writing at any time.
Prior Express Consent for Calls, Texts, & Emails
*
Yes
No
By providing phone numbers and email addresses now or in the future, I consent and agree that Bay Area Orthodontics may call me, leave me a voicemail, or send me a text, email or other electronic message for the purposes relating to the servicing or collection of any account that I may establish with BAO or any other informational purposes related to my account or treatment (“Communication”). I also agree that BAO may include my personal information in a communication. BAO will not charge for a communication, but my service provider may. I agree that BAO may monitor and record any telephone calls to assure the quality of its service or for other reasons.
Information Verification
*
Yes
No
INFORMATION VERIFICATION | I, the primary responsible acknowledge that the information provided herein is true and complete to the best of my knowledge. I authorize Bay Area Orthodontics or anyone acting on my behalf to obtain, review and/or share with its designated agents, or any assignee of my account, my information for the purpose of verifying my identity, or updating, renewing, servicing, modifying, or collecting my account. This authorization is valid as long as any amounts are owed on my account to Bay Area Orthodontics or any assignee of my account. I acknowledge that BAO may report information about my account to consumer reporting agencies and other persons who may legally receive such information. Late payments, missed payments or other default on my account may be reflected in my credit report.
Primary Name of Responsible Party
*
First
Last
Date
Next
Next
Name of Individual or Legal Representative
*
First
Last
Witness Name
*
First
Last
Date
*
Name
*
First
Last
I have read and understand the Office Information provided above and agree to abide by its contents:
Date
Next
Patient Name
*
First
Last
Patient Birth Date:
*
Nickname
*
Gender
*
Male
Female
Other
Person Completing This Form
*
First
Last
Relationship to Patient
*
Parent
Step Parent
Self
Other
Relationship to Patient if Other
*
Next
Does the patient see a dentist for routine exams and cleanings?
Yes
No
Has the patient ever had a reaction from local anesthetic?
Yes
No
Does the patient have any of the following habits?
Thumb/Finger Sucking
Clenching/Grinding Teeth
Snoring/Sleep Apnea
Is patient in good health?
Yes
No
Are the patient’s immunizations up to date?
Yes
No
Is the patient taking any medication?
Yes
No
Has the patient ever been premedicated with antibiotics for your dental treatment?
Yes
No
Has the patient had any trouble associated with dental treatment?
Yes
No
Has the patient ever had a serious illness or surgery or been in the hospital overnight?
Yes
No
Has the patient ever had a blood transfusion?
Yes
No
Does the patient have any tubes, shunts, prosthesis?
Yes
No
Has the patient had complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions?
Yes
No
Next
Allergies
Yes
No
Asthma, Medication:
Yes
No
Diabetes, medication:
Yes
No
Heart disease
Yes
No
Blood disorders
Yes
No
Excessive bleeding after dental treatment
Yes
No
Cancer or chemotherapy
Yes
No
Radiation treatment of any kind
Yes
No
Hepatitis or liver disease
Yes
No
Hearing loss
Yes
No
Kidney disease
Yes
No
Respiratory disease
Yes
No
Epilepsy or seizures
Yes
No
Behavior problems/learning disability
Yes
No
Cerebral Palsy
Yes
No
Autism
Yes
No
Developmental or constitutional delay, functional age level:
Yes
No
Skin rash
Yes
No
Is there any other medical condition or syndrome from which the patient suffers?
Yes
No
Doctor
First
Last
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BAO
Dr. Kim
Services
Bay Area Orthodontics Patient Care
Emergency
Contact Us
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408-715-2712