New Patient Form - Bay Area Orthodontics

Patient Name *

First

Last

Preferred Name or Nick Name

Address *

Address Line 1

Address Line 2

City

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?

Which Office Have They Been to Before?

Does the Patient Have a Sibling That Has Been Seen In Our Office(s) Before?

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

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

State

Zip Code

Secondary Responsible Person Relation to Patient

Biological Parent
Step-Parent
Other

Describe Secondary Responsible Person Relation to Patient

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

State

Zip Code

Insured's SSN#

Employer

Employer's Phone #

Group #

Policy Number

Policy Effective Date

Union Name and Local Union #

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 #

Photo Consent *

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 *

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 *

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

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

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 *

Does the patient see a dentist for routine exams and cleanings?

Has the patient ever had a reaction from local anesthetic?

Does the patient have any of the following habits?

Thumb/Finger Sucking
Clenching/Grinding Teeth
Snoring/Sleep Apnea

Is patient in good health?

Are the patient’s immunizations up to date?

Is the patient taking any medication?

Has the patient ever been premedicated with antibiotics for your dental treatment?

Has the patient had any trouble associated with dental treatment?

Has the patient ever had a serious illness or surgery or been in the hospital overnight?

Has the patient ever had a blood transfusion?

Does the patient have any tubes, shunts, prosthesis?

Has the patient had complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions?

Allergies

Asthma, Medication:

Diabetes, medication:

Heart disease

Blood disorders

Excessive bleeding after dental treatment

Cancer or chemotherapy

Radiation treatment of any kind

Hepatitis or liver disease

Hearing loss

Kidney disease

Respiratory disease

Epilepsy or seizures

Behavior problems/learning disability

Cerebral Palsy

Autism

Developmental or constitutional delay, functional age level:

Skin rash

Is there any other medical condition or syndrome from which the patient suffers?

Doctor

First

Last

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