Health History

"*" indicates required fields

Submit Your Health History Online

Save time at the doctor’s office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the “Submit” button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.

Patient Information

Which office location will you be visiting?*

First Name*

Middle Name

Last Name*

Gender*

Male

Female

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Cell Phone*

Email*

Responsible Party Information

Responsible Party*

First Name*

Middle Name

Last Name*

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Work Phone

Cell Phone*

Email*

Date of Birth*

Marital Status*

Does this person live in the same household as the patient?*

S.S. #*

Emergency Contact*

Emergency Contact Phone*

Responsible Party Employer Information

Employer Name*

Address

Street Address Address Line 2 City State ZIP / Postal Code

No. Years Employed

Occupation

Insurance Company Name

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Phone Extension

Group #

Policy #

Orthodontic Coverage?

Yes

Not Sure

Second Responsible Party Information

Is There a Second Responsible Party?

Yes

Responsible Party*

Father

Mother

Spouse

Other

First Name*

Middle Name

Last Name*

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Work Phone

Cell Phone

Date of Birth*

Marital Status*

Does this person live in the same household as the patient?*

S.S. #*

Emergency Contact*

Emergency Contact Phone*

2nd Responsible Party Employer Information

Employer Name

Address

Street Address Address Line 2 City State ZIP / Postal Code

No. Years Employed

Occupation

Insurance Company Name

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Phone Extension

Group #

Policy #

Orthodontic Coverage?

Yes

Not Sure

Other Information

Dentist Name

Who may we thank for referring you to our office?

Do you have other children?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Add additional child?

Yes

Child's Name

Age

Medical Information

Explain any "yes" answers

List any allergies

List any medications the patient is taking

List any problems not mentioned above that we should know about

Dental History

In your own words, what is the orthodontic problem?*

What would you like orthodontic treatment to accomplish?*

TCPA

In order for us to send text appointment reminders the Telephone Consumer Protection Act (TCP) enacted by the Federal Communications Commission (FCC) requires a signature from you to receive automated phone calls from the office of:

Dr. J. Matthew Elison @ Elison and Wood Orthodontics
Dr. Ryan L. Wood @ Elison and Wood Orthodontics

“I,

Name*

First Last

, hereby consent to receive autodialed and/or pre-recorded appointment reminder calls and recall reminder calls from/or on behalf of Dr. J. Matthew Elison @ Elison and Wood Orthodontics and Ryan L. Wood @ Elison and Wood Orthodontics at the telephone number(s) provided”

I understand that consent is not a condition of services
Effective October 16, 2013

Home phone number

Father's CELL phone number

Mother's CELL phone number

Mother's WORK phone number

Father's WORK phone number

Enter the Preferred number for your automated messages*

Email address

Names of patient(s) in treatment

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Privacy Consent

This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office’s privacy notice prior to signing this Consent, a copy of which was given to you with this Consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.

Thank you for your cooperation. Please let us know if you have any questions.

Patient / Parent / Guardian's Signature*

Date*

Health History

Submit Your Health History Online

Patient Information

Responsible Party Information

Responsible Party Employer Information

Second Responsible Party Information

2nd Responsible Party Employer Information

Other Information

Medical Information

Dental History

TCPA

Privacy Consent

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