New Patient Form - GO Invisalign Orthodontics Tampa

Patient First Name/Nombre del Paciente:**

Patient Last Name/Apellido del Paciente:**

The following information is for a(n)/La siguiente información es para un:*

Adult/Adultos

Child/Menores de 18 años

Gender/Género:*

Male

Female

Patient Birthdate/Fecha de Nacimiento:*

Patient Information

Address

Address Line1 Address Line 2 City State Zip

Home Phone #:

Cell Phone #:*

Patient Dentist:

Dentist Phone #:

Email*

Who may we thank for your referral?

Other family members seen by us?

Responsible Party Information

Responsible Party Name:*

Relationship to patient:*

Phone*

Address

Address Line1 Address Line 2 City State Zip Code

Contact in case of Emergency (Name):*

Phone*

Relationship to patient*

HIPAA Consent

Authorization for Cell Phone and Email Use

Select all that apply:*

Text

None

Cell Phone #1:

Email #1:

Cell Phone #2:

Email #2:

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

I hereby consent to the collection and use of my personal images by photography or video recording.
I understand without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to GO Orthodontics Tampa 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 further acknowledge that GO Orthodontics Tampa may use my image in media to promote the practice in the future with my consent authorization.
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I also understand that my consent can be withdrawn at anytime in writing to GO Orthodontics Tampa.

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

Agree

Disagree

Practice Policy and the use of Social Media

GO Orthodontics Tampa (the “Practice”) understands and appreciates the important role that social media plays in a providing feedback on the quality of the services that the Practice provides before, during, and after you/your child’s treatment. However, as a dental practice we are limited in our ability to publicly address the feedback that is published on social media due to patient confidentiality laws. In an effort to ensure that we receive accurate, fair and honest feedback from you, and to prevent the publishing of false and or inaccurate content in any form and in any medium, the Practice has developed this policy to provide a process to reasonably and timely address your concerns, complaints, or other issues without resorting to social media.

By initialing below and authorizing the Practice to treat you/your child, you agree that you or anyone on your behalf, will not post any inaccurate and/or negative review, criticism, complaint, or comment about the Practice and/or any of its dentists or staff members without first notifying the Practice directly, by phone or email, of your concern, criticism, complaint, or other issue and allowing the Practice a reasonable period of time not to exceed 30 days from the date of service at issue to directly address your concern, complaint, or other issue. Such services to which this policy applies include, but are not limited to, billing issues, medication requested, consultation issues, x-ray or MRI testing, clinical, administrative procedures, treatments, and/or personnel issues relating to the Practice’s dentists and/or staff members.

If you violate the terms of this policy, then you have forty-eight (48) hours to retract your review, criticism, complaint and/or comment from the date of posting. In the event that you do not retract your review, criticism, complaint and/or comment within such time period, in whole or in part, the Practice hereby reserves the right to pursue any and all legal and equitable remedies available to it under applicable law, including, but not limited to, terminating your/your child as a patient of the Practice. You agree to assume all legal costs arising, and the fair compensation for damages no limited to the reputation and/or loss of income of the Practice. You also agree to assume all costs and fees associated with the termination of your / your child’s treatment with us and the continuation of the remaining treatment with a new provider.

For the avoidance of doubt, and due to the rapidly expanding world of electronic communication, social media can mean many things. As referenced in this policy, social media includes all means of communication or posting information or content of any sort on the Internet, including to your or to someone else’s blog, journal or diary, personal website, social networking or affinity website, web bulletin board or a chat room, as well as any other form of electronic communication.

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

Agree

Disagree

Dental Insurance

Does the patient have Dental Insurance?*

Yes

Name of Insured:*

Birthdate:

Relationship to patient*

Employer of Insured:*

ID Number of Insured:*

Name of Ins Company:*

Phone # of Ins Company:*

Group #:

Your Dental History

Date of Last Dental Cleaning:*

Any Pending Treatement*

Yes

Does the patient have gum disease?*

Yes

Any Treatment?

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

Yes

Explain your injury:

Has the patient had or do you presently have any of the following habits?*

Tongue

Thumb

Finger

Lip sucking

clenching/grinding

Mouth Breathing

NONE

Other

Other habits:

Does the patient have any speech problems?*

Yes

Any pain, popping, or locking on opening or closing jaw?*

Yes

Any muscle tenderness or stiffness in the:*

Jaw

Neck

None

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

Yes

Any previousa treatment for TMJ or jaw problems?*

Yes

Has an orthodontist been consulted previously?*

Yes

Orthodontist's Name:

What Age?

Reason for treatment:

Notes

Medical History

Are you under the care of a physician?*

Yes

Reason for physician care:

What is the name of your family physician?

Date of last physical:

Is the patient taking any medication?*

Yes

Medication Names:*

Has the patient had their tonsils removed?*

Yes

Please list details:

Does the patient have any allergies? (Latex / Nickel / Nuts)*

Yes

Does the patient have any drug allergies?*

Yes

List allergies:*

Has the Patient reached puberty?*

Yes

Started Menstruation?*

Yes

Date Started:*

Does the patient have now, or has the patient ever had any of the following?

(Please check if YES or leave unchecked for NO)

Any medical conditions that you should make us aware of?

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.

GO Orthodontics Tampa 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*

Use your mouse or finger to draw your signature above