Step 1 of 6 16% WELCOME TO CC BRACESADULT’S INFORMATIONPatient’s Legal Name*Gender*MaleFemalePreferred NameResidence Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you been at this address?*Less than 1 yearMore than 1 yearPrevious Residence Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address same as residence address?*YesNoMailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Home PhoneAppointment reminders OK via text*YesNoEmail* Social SecurityDate of Birth* MM DD YYYY Marital Status*SingleMarriedDivorcedWidowedEmploymentEmployerOccupationYears EmployedSpouseSpouse’s Name*Phone*Date of Birth* MM DD YYYY Social SecurityEmployerOccupationYears Employed Insurance InformationPlease allow us to make a copy of your insurance cardDental coverage?*YesNoOrthodontic Coverage?*YesNoDon't knowSubscriber's Name*Name of Policy HolderSubscriber's Date of Birth* MM DD YYYY Member ID or SS#*Employer*Insurance Carrier*Emergency InformationEmergency Contact Name*Name of nearest relative not living with youPhone Number* Medical InformationGeneral DentistGeneral Dentist Office Name*Dentist Office PhoneDate of Last cleaning/checkup* MM DD YYYY Family PhysicianDoctor's NameOffice PhoneDate of Last Exam MM DD YYYY Dental/Medical HistoryPermanent or extra (supernumerary teeth) teeth removed?*YesNoDon't knowPlease specify*Supernumerary (extra) or congenitally missing teeth?*YesNoDon't knowPlease specify*Bleeding gums, Sensitive or sore teeth? Food impaction between teeth?*YesNoDon't knowPlease specify*Chipped, or injured primary or permanent teeth? Any broken or missing fillings?*YesNoDon't knowPlease specify*Any teeth treated with root canals or pulpotomies?*YesNoDon't knowPlease specify*Frequent canker sores or cold sores? Teeth causing irritation to lip, cheek of gums?*YesNoDon't knowPlease specify*Jaw fractures, cysts, infections?*YesNoDon't knowPlease specify*Any soreness in jaw muscles / Clicking or locking of the jaw / Tooth grinding or clenching?*YesNoDon't knowPlease specify*History of speech problems or speech therapy / Abnormal swallowing (tongue thrust)?*YesNoDon't knowPlease specify*Difficulty breathing through the nose / Mouth breathing habit or snoring at night?*YesNoDon't knowPlease specify*Ever treated for TMJ or TMD problems / Ringing in ears, difficulty in chewing or opening jaw?*YesNoDon't knowPlease specify*Any injuries to face, head, neck?*YesNoDon't knowPlease specify*What concerns do you have about your teeth/smile?Who suggested that you might need orthodontic treatment?Why did you select our officeHave you had any previous orthodontic treatment or consultation?*YesNoPlease describe*Have you had any family members treated here?*YesNoPlease provide namesDo your think that any of your work or leisure activities affect your teeth or jaws?*YesNoPleaes specify*Frequent oral habits (sucking finger, chewing pen etc)?*YesNoPlease specify*Is there dental work or gum treatment needed or is progress?*YesNoPlease specify*Have you head a negative reaction to dental care?*YesNoPlease specify*Do you are have you ever had a substance abuse problem?*YesNoPlesse specify*Do you smoke or chew tobacco?*YesNoPlease specify*Angina, arteriosclerosis, stroke or heart attack? Chest pain, shortness of breath, tire easily, swollen ankles?*YesNoPlease specify*Women OnlyAre you pregnant?*YesNoAre you trying to become pregnant?*YesNo Diseases / AllergiesHave you ever had or been treated by a physician for* Heart disease or defects, Murmur Birth defects, Hereditary problems Immune systems problems Rheumatic Fever Diabetes or low sugar Abnormal Bleeding/Hemophilia Kidney Disease Hepatitis, Liver Disease AIDS/HIV+ Eating disorder, anorexia, bulimia Arthritis or joint problems Seizures, fainting spells, neurologic problems High or Low blood pressure Tuberculosis, mononucleosis Frequent ear, throat infections Vision or Hearing Problems Tonsils/Adenoids/Sinus Problem Eye Problems/Contact Lenses Mental Health/Depression Do you eat a well-balanced diet Headache/Migraines Cancer, Tumor, Chemotherapy, Radiation Therapy Endocrine/Thyroid Problems Skin disorder Artificial Joints/Valves Bone Fractures, major injuries Osteoporosis, bone disorder Stomach ulcer, acid reflux Asthma, sinus, hayfever Polio, tuberculosis, mononucleosis NONE Other Have you had allergies or reactions to any of the following* Local anesthetics (novocaine, lidocaine, xylocaine) Latex (gloves, balloons) Plastic Aspirin or ibuprofen )Motrin, Advil) Metals (jewelry, clothing snaps) Acrylics Penicillin, Other antibiotics Plant pollens, Animals Food Other substances None Food list*Other substances List*Please list any medical problems you have that might have an effect on your treatment in our office*Entry NA if not applicableList all current medications, and any additional comments…*Type NA if not applicableIf you have ever taken any medications to strengthen your bones, please describe*Enter NA if not applicableRelease and Waiver*I authorize release of any information regarding my child’s orthodontic treatment to my dental and or medical insurance company. I have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form.I will notify my orthodontist of any changes in my child’s medical or dental health I consent to above policy.Signature of Patient or Legal Guardian*Date HIPAA PolicyPrivacy Policy*PRIVACY POLICY THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I have clicked on the link above and read the document.Signature*Date Authorization to Release Patient Record InformationI, hereby authorize CC Braces to disclose facial and/or dental photographs, photographs, and video of the following patient as approved below:May the patient's picture be displayed on the reception computer screen for patient sign-in purposes?*YesNoMay the patient's picture be displayed on the office website, Blog, Social Media accounts and/or within the office for the purpose of informing patients of the positive outcome we have achieved?*YesNoMay the patient's picture be displayed on the office website, Blog, Social Media account and/or within the office if they are a contest prize winner?*YesNoMay the patient's records including photographs be used for the purposes of professional consultations, research, education or publication in professional journals?*YesNoPlease Note*Financial Disclosure: I understand that the practice is not receiving compensation from anyone for use of the patient's photo. Refusal to Sign: I understand that refusal to sign part or all of this Authorization will in no way affect the patient's treatment. Revocation: I understand that I may revoke this authorization at any time by sending a written notice to the practice. All photos will be removed at the time the revocation is received. I certify that I am the authorized representative for the patient.Signature*Date
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