Deborah L Fox DDS PC
Patient Information
Patient's Last Name ________________________ First Name ______________________ Middle Initial ______ Prefers To Be Called __________________ Birth Date ______________ Age _____ Sex: Home Address ______________________________________________ Phone # to be used for appointment reminders: _________________________ Patient’s Dentist __________________________________ Patient’s Physician ___________________________________ How did you hear about our office? ______________________________________________________________________________ List brothers /sisters with age: ________________________________________________________________________________ Parent/Guardian Information
Patient lives with (check all that apply) Father's Full Name _______________________________________ E-Mail Address _______________________________
Address (if different) _____________________________________________________ Birth Date ______________ Employer _______________________________ Home Phone (_______) ______-_______ Cell Phone (______) ______-________ Work Phone (______) ______-________ Mother’s Full Name _____________________________________ E-Mail Address _______________________________
Address (if different) _____________________________________________________ Birth Date ______________ Employer _______________________________ Home Phone (_______) ______-_______ Cell Phone (______) ______-________ Work Phone (______) ______-________ Financial Responsibility
Who is financially responsible for this account? ____________________________________ Address ________________________________________________ City, State, Zip___________________________ Home Phone (______) _____-_______ Cell Phone (______) ______-________ E-Mail Address_________________________ Social Security # ______ -_____ -_______ Employer:________________________________________ Dental Insurance
Primary Insurance Carrier:__________________________________ Policy ID# ___________________ Group #_____________
Insurance Address and Phone __________________________________________Social Security # _______ -____ -________ Subscriber/Parent who holds policy ___________________________________________Birth Date ________________ Employer who provides the insurance______________________ _______________________________ Does this policy have orthodontic benefits? Secondary Insurance Carrier:________________________________ Policy ID# ___________________ Group #_____________
Insurance Address and Phone __________________________________________Social Security # _______ -____ -________ Subscriber/Parent who holds policy ___________________________________________ Birth Date ________________ Employer who provides the insurance______________________ _______________________________ Does this policy have orthodontic benefits? I authorize Dr. Fox and staff to communicate with my dentist and my dental insurance company/companies. Parent/Guardian Signature ____________________________________________________________ ************************************************************************************************************ HIPAA
By signing below, I hereby acknowledge that I have been provided with a copy of this office’s Notice of Privacy Practices and have therefore been advised of how my protected health information may be used and disclosed by the office and how I may obtain access to and control this information. In addition, by signing below, I hereby consent to the use and disclosure of my health information for treatment purposes, payment activities and healthcare operations of the office as described in the Notice. Signature of the Patient/Person Responsible: _____________________________________________ Print Full Name: _____________________________________________________________________ Date: _____________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Patient's Last Name ________________________ First Name ______________________ Middle Initial ______ Your answers are for office records only, and are confidential.
A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes or no.
Now or in the past, has your child had:

no Birth defects or hereditary problems?
no Mental health disturbance or depression?
no Bone fractures, or major injuries?
no Frequent headaches or migraines?
no Any injuries to face, head, neck?
no High or low blood pressure?
no Arthritis or joint problems?
no Require antibiotic premedication?
no Endocrine or thyroid problems?
no Skin disorder (other than common acne)?
no Diabetes or low sugar?
no Does your child eat a well-balanced diet?
no Kidney problems?
no Vision, hearing, or speech problems?
no Immune system problems?
no Asthma, sinus problems, hayfever?
no History of osteoporosis?
no Tonsil or adenoid condition?
no AIDS or HIV positive?
no Hepatitis, jaundice or other liver problems?
no Cancer, tumor, radiation treatment or chemotherapy?
no Gonorrhea, syphilis, herpes, sexually transmitted diseases?
no Polio, mononucleosis, tuberculosis, pneumonia?
no History of eating disorder (anorexia, bulimia)?
no Seizures, fainting spells, neurologic problem?
no Excessive bleeding or bruising tendency, anemia?
no Chest pain, shortness of breath, tire easily, swollen ankles?
no Heart defects, heart murmur, rheumatic heart disease?
no Angina, arteriosclerosis, stroke or heart attack?
no Frequent ear infections, colds, throat infections?
no Does your child frequently breathe through his/her mouth?
no Has your child ever taken intravenous bisphosphonates such
as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer? no Has your child ever taken oral bisphosphonates such as
Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
Has your child had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine) Any other medications _________________________________________________________ Any other allergies ____________________________________________________________
Now or in the past, has the patient had:

no Erupting teeth very early or very late?
no Primary (baby) teeth removed that were not loose?
no Permanent or extra (supernumerary) teeth removed?
no Supernumerary (extra) or congenitally missing teeth?
no Chipped or injured primary or permanent teeth?
no Any sensitive or sore teeth?
no Any lost or broken fillings?
no Jaw fractures, cysts, infections?
no Any teeth treated with root canals or pulpotomies?
no Frequent canker sores or cold sores?
no History of speech problems or speech therapy?
no Difficulty breathing through nose?
no Mouth breathing habit or snoring at night?
no Frequent oral habits (sucking finger, chewing pen, etc.)?
Please explain: _______________________________________________________ no Teeth causing irritation to lip, cheek or gums?
no Tooth grinding or clenching?
no Clicking, locking in jaw joints?
no Soreness in jaw muscles or face muscles?
no Any serious trouble associated with previous dental treatment?
no Has your child ever been diagnosed with gum disease?
Do you think that any of your child’s activities affect his/her face, teeth or jaws? How? ___________________________________________ List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes. Medication _____________________________ Taken for __________________________ Medication _____________________________ Taken for __________________________ Medication _____________________________ Taken for __________________________ Is there anything else we should know about your child: ____________________________________________________________ _________________________________________________________________________________________________________ I have read the above questions and understand them. I will not hold Dr. Fox or any member of her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify Dr. Fox of any changes in my child’s medical or dental health. Parent/Guardian Signature ____________________________________________________________


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