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Office
Patient
Orthodontics
Pediatric Dentistry
Patient Forms

Orthodontic Adult New Patient Form

McCalla Orthodontics & Pediatric Dentistry » Patient » Patient Forms » Orthodontic Adult New Patient Form

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We believe that excellent care begins with open communication. If you need more information, have any questions, or want to schedule an appointment, please contact us!

McCalla Orthodontics & Pediatric Dentistry

4814 Bell Hill Rd.
Bessemer, AL 35022
(205) 477-8004

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Office Hours

Monday – Thursday: 8:00 a.m. – 5:00 p.m.
(Closed daily: 11:30 a.m. – 1:00 p.m.)
Selected Fridays

_2017 Adult Registration Form – Ortho

Patient Information

* Patient Name: (Required)

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

Employer's Name:

Occupation:

Spouse / Partner Information

Spouse/Partner's Name:

Marital Status: Single Married Divorced Widowed Significant Other

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Emergency Contact Information

Emergency Contact's Name:

Phone Number:

Relation to Patient:

Address:

City:

State:

Zip:

Person(s) OK to release appointment or medically-related information to:

Relation to Patient:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

General Dentist:

Last Visit:

How did you hear about our practice? Ad Internet Family/Friend Physician Other

Name of person referring (if applicable):

What are the main concerns you would like orthodontics to correct?

Have you visited an orthodontist before? Yes No

If yes, when:

Reason:

Have your tonsils or adenoids been removed? Yes No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Do you have any missing or extra permanent teeth? Yes No

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

Do you have speech problems? Yes No

If so, explain:

Do your gums bleed? Yes No

Do you smoke? Yes No

Do you like your smile? Yes No

Do you currently or have you ever had any of the following habits (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem

Medical History

Are you currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion? Yes No

If yes, give approximate dates:

(Women) Are you pregnant? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

Check if you have ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)

Authorization

Assignment of Benefits (if covered by insurance): I direct that my insurance company pay the benefits for treatment directly to McCalla Orthodontics and Pediatric Dentistry. I assign to the dental office for the purpose of security, any right I may have to receive such payment directly from the insurance company, and hereby revoke any prior authorizations which I may have given to the contrary. I agree to cooperate fully with the office efforts to obtain payment under such policy and will execute any additional documents my insurance company may require in order to process the office claim. In the event of any overpayment of insurance benefits, (as where two policies are subject to a coordination of benefits) I authorize McCalla Orthodontics and Pediatric Dentistry to refund to the company making such over payment.

Payment Policy: I understand that by signing below I agree to pay for services rendered, whether or not I am the patient. I agree that I will pay this bill in full whether or not charges are or should have been covered by insurance. I have been advised that the office does not extend credit and that payment is due in full at time of service. I agree that if this account is not paid when due, and if the office should refer it to an attorney or collection agency for collection, I agree to pay collection agency fees (33.33%), attorney fees and/or court costs. I also agree to pay interest on past due balances of 1.5 % per month (18 % APR). I hereby waive all rights of emption which are available to me under the law of Alabama or the United States.

Any returned checks will be assessed a $35.00 charge. By law, your bank informs you of a dishonored check. We expect you to contact us to make arrangements for settling the full amount of the check plus $35.00 within ten (10) days. Late payment charges will be assessed if the matter is not settled by that time. All other policy provisions as noted above apply, including collection.

We thank you for your cooperation and look forward to providing the highest quality dental care for your children with a clear understanding of each party's responsibilities.

Appointment Cancellation Policy: We require a 48 hour notice of change in appointments. We reserve the right to charge a $40.00 fee for missed appointments and appointments changed with less than 48 hour notice.

Telephone Consumer Protection Act (TCPA): You agree, in order for us to service your account or to collect monies you may owe, McCalla Orthodontics and Pediatric Dentistry, and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using prerecorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and financial policy and accept all provisions. I/We also agree that McCalla Orthodontics and Pediatric Dentistry, its employees and/or agents may contact me/us as described above.

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Date:

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