Adult Registration Forms Step 1 of 7 0% Patient InformationFirst Name(Required) Last Name(Required) Birth Date(Required) MM slash DD slash YYYY Sex(Required)MaleFemaleNon-binaryMarital Status(Required)SingleMarriedSeparatedDivorcedWidowStreet Address(Required) City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code(Required) Phone Number(Required)Phone Type(Required)Home PhoneCell PhoneWork PhoneSecond Phone NumberSecond Phone TypeHome PhoneCell PhoneWork PhoneEmail Address(Required) Occupation Employer Closest RelativeSpouse or closest relatives name(s)(Required) Relationship to Patient(Required) Address (if different from patient 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 Phone Number(Required)Phone Type(Required)Home PhoneCell PhoneWork PhoneDentistPatient's Dentist Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Last Seen Month Day Year Reason Other dentists/dental specialists now being seenNameCity, StateReason Add RemovePhysicianPatient's Physician Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Last Seen Month Day Year Reason Other physicians being seenNameCity, StateReason Add Remove General InformationWhat concerns you about your teeth? Who suggested you might need orthodontic treatment? Why did you select our office? If you've had previous orthodontic treatment, please describe. If any family members have been treated in this office, please name them. Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain. Financial ResponsibilityWho is financially responsible for this account?(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Phone Type(Required)Home PhoneCell PhoneWork PhoneEmail(Required) Dental InsuranceDo you have dental insurance?(Required) Yes No Policy holder's full name(Required) First Last Date of birth(Required) Month Day Year Relationship to patient(Required) Address (if not listed previously) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Employer address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance company(Required) ID Number(Required) Does this policy have orthodontic benefits?(Required) Yes No Don't know Do you have a secondary policy? Yes No Policy holders full name(Required) First Last Birth date(Required) Month Day Year Relationship to patient(Required) Address (if not listed previously) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Employer address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance company(Required) ID Number(Required) Does this policy have orthodontic benefits?(Required) Yes No Don't know Medical HistoryMedical History 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, no, or don't know/understand (dk/u). Now or in the past have you had: Birth defects of heredity problems?(Required) Yes No Please explain Bone fractures or major injuries?(Required) Yes No Please explain Any injuries to the face, head, neck?(Required) Yes No Please explain Arthritis or joint problems?(Required) Yes No Please explain Endocrine or thyroid problems?(Required) Yes No Please explain Diabetes or low sugar?(Required) Yes No Please explain Kidney problems?(Required) Yes No Please explain Cancer, tumor, radiation treatment or chemotherapy?(Required) Yes No Please explain Stomach ulcer, hyperacidity, acid reflux?(Required) Yes No Please explain Immune system problems?(Required) Yes No Please explain ADD/ADHD?(Required) Yes No Please explain History of osteoporosis?(Required) Yes No Please explain Sexually transmitted diseases?(Required) Yes No Please explain AIDS or HIV?(Required) Yes No Please explain Hepatitis, jaundice or other liver problems?(Required) Yes No Please explain Mononucleosis, tuberculosis, pneumonia?(Required) Yes No Please explain Seizures, fainting spells, neurologic problems?(Required) Yes No Please explain Mental health disturbance or depression?(Required) Yes No Please explain Vision or hearing problems?(Required) Yes No Please explain History of eating disorder?(Required) Yes No Please explain High/Low blood pressure?(Required) Yes No Please explain Excessive bleeding or bruising, anemia?(Required) Yes No Please explain Chest pain, shortness of breath, tire easily, swollen ankles?(Required) Yes No Please explain Heart defects, heart murmur, rheumatic heart disease?(Required) Yes No Please explain Angina, atherosclerosis, stroke or heart attack?(Required) Yes No Please explain History of eating disorder?(Required) Yes No Please explain Skin disorder (other than common acne)?(Required) Yes No Please explain Do you eat a well-balanced diet?(Required) Yes No Please explain Frequent headaches or migraines?(Required) Yes No Please explain Frequent ear infections, colds, throat infections?(Required) Yes No Please explain Asthma, sinus problems, hay fever?(Required) Yes No Please explain Tonsil or adenoid condition?(Required) Yes No Please explain Do you frequently breathe through your mouth?(Required) Yes No Please explain Have you had allergies or reactions to the following:Local anesthetics (novocaine, lidocaine, xylocaine, etc.)(Required) Yes No DK/U Please explain Latex(Required) Yes No DK/U Please explain Aspirin(Required) Yes No DK/U Please explain Metals (jewelry, clothing, snaps)(Required) Yes No DK/U Please explain Penicillin(Required) Yes No DK/U Please explain Other antibiotics(Required) Yes No DK/U Please explain Plant pollens(Required) Yes No DK/U Please explain Ibuprofen(Required) Yes No DK/U Please explain Acrylics(Required) Yes No DK/U Please explain Foods(Required) Yes No DK/U Please explain Animals(Required) Yes No DK/U Please explain Other substances(Required) Yes No DK/U Please explain Dental HistoryNow or in the past have you had:Permanent or extra (supernumerary) teeth removed?(Required) Yes No DK/U Please explain Supernumerary (extra) or congenitally missing teeth?(Required) Yes No DK/U Please explain Chipped or injured primary or permanent teeth?(Required) Yes No DK/U Please explain Sensitive or sore teeth?(Required) Yes No DK/U Please explain Bleeding gums, bad taste or mouth odor?(Required) Yes No DK/U Please explain Jaw fractures, cysts, infections?(Required) Yes No DK/U Please explain Any teeth treated with root canals or pulpotomies?(Required) Yes No DK/U Please explain Frequent canker sores or cold sores?(Required) Yes No DK/U Please explain History of speech therapy or speech problems?(Required) Yes No DK/U Please explain Difficulty breathing through nose?(Required) Yes No DK/U Please explain Food impaction between teeth(Required) Yes No DK/U Please explain Mouth breathing habit or snoring at night?(Required) Yes No DK/U Please explain Frequent oral habits (sucking finger, chewing pen, etc.)?(Required) Yes No DK/U Please explain Teeth causing irritation to lip, cheek or gums?(Required) Yes No DK/U Please explain Abnormal swallowing (tongue thrust)?(Required) Yes No DK/U Please explain Tooth grinding or clenching?(Required) Yes No DK/U Please explain Clicking, locking in jaw joints?(Required) Yes No DK/U Please explain Soreness in jaw muscles or facial muscles?(Required) Yes No DK/U Please explain Ringing in ears, difficulty in chewing or opening jaw?(Required) Yes No DK/U Please explain Have you ever been treated for "TMJ" or "TMD" problems?(Required) Yes No DK/U Please explain Any broken or missing fillings?(Required) Yes No DK/U Please explain Any serious trouble associated with previous dental treatment?(Required) Yes No DK/U Please explain Have you ever been diagnosed with gum (periodontal) disease or pyorrhea?(Required) Yes No DK/U Please explain Have you ever had an orthodontic consultation or treatment before now?(Required) Yes No DK/U Please explain Patient health informationList any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.List current medicationsMedicationTaken for Add RemoveHave you ever taken intravenous bisphosphonates such as Zometa (solendromic acid, Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?(Required) Yes No DK/U Please explain Have you ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?(Required) Yes No DK/U Please explain Have you ever taken any medications to strengthen your bones?(Required) Yes No DK/U Please explain Do you or have you ever had a substance abuse problem?(Required) Yes No DK/U Please explain Do you chew or smoke tobacco?(Required) Yes No DK/U Please explain Have you noticed any changes in your face or jaws?(Required) Yes No DK/U Please explain Any other physical problems?(Required) Yes No DK/U Please explain How often do you brush?(Required) How often do you floss?(Required) Women: are you pregnant?(Required) Yes No DK/U Women: are you trying to become pregnant?(Required) Yes No DK/U Family Medical HistoryBleeding disorders?(Required) Yes No DK/U Please explain Diabetes?(Required) Yes No DK/U Please explain Arthritis(Required) Yes No DK/U Please explain Severe allergies?(Required) Yes No DK/U Please explain Unusual dental problems?(Required) Yes No DK/U Please explain Jaw size imbalance?(Required) Yes No DK/U Please explain Other family medical conditions?(Required) Yes No DK/U Please explain Office PolicyScheduling and AppointmentsOur office hours are Monday 9-6, Tuesday through Thursday 8-5 and Friday 8-1 (administrative only). Appointments are usually scheduled at four (4) to eight (8) week intervals during treatment. The majority of these visits can be scheduled in the early morning or afternoon; however, appointments 1 hour or longer (putting braces on, taking braces off, impressions) need to be scheduled in the morning or early afternoon. We do understand that this may be inconvenient for some patients, but it does allow us to provide our best possible treatment and also to accommodate as many patients as possible during the afternoon hours. It is the patient’s responsibility to make timely follow-up appointments. These can be scheduled after your visit, and are therefore, scheduled in advance. This will help to ensure that you can choose times/days that will work for you or give you ample notice to make arrangements. If you wait until the week before to attempt to schedule your followup visit you probably will not be able to get your most ideal time slot. Your appointment is reserved especially for you, and so we do require 24 hours notice to cancel. If you are 10 minutes late for your appointment please understand that we will likely need to reschedule your appointment in order to prevent inconvenience to the rest of our patients. Repeated missed appointments or last-minute cancellations may result in rescheduling fees. As a courtesy to you we confirm your appointment 1-2 days prior, but please do not depend on this, since messages can be accidentally erased or overlooked.Treatment CooperationWe will always do our best to provide the absolute best orthodontic treatment for our patients, because we care. In return, we expect excellent treatment cooperation. This common goal for doctor and patient is what results in superior orthodontics. Below you will find a list of our expectations for all of our patients and/or parents: • Cooperation in elastic wear • Proper oral hygiene • Maintaining regular dental cleanings and checkups with your general dentist (every 3 months) • Keeping of regular adjustment appointments at recommended intervals • Eliminating foods and eating habits that break or distort appliances • Reporting lost or broken appliances promptly At the least, poor compliance will extend treatment time, and at the most, it may even prevent us from completing your treatment at all. In these extreme cases we will be obligated to terminate active treatment. Financial PolicyWhen treatment is initiated we will draw up a financial agreement (contract), so that the terms of payment are clear. We offer a 5% courtesy for payment in full, or we can finance over the anticipated length of treatment with monthly payments. Payments are accepted in the form of cash, personal check, and credit card (Visa, Mastercard, Discover, American Express). Please be aware that there is a $40 charge for returned checks, and multiple instances may result in our accepting cash-only payments. A monthly payment is a convenient way to spread out the cost of orthodontic treatment and is not related to treatment progress or appointments; therefore, payment is still collected even if there is no appointment during the month. For your convenience we do offer an autopay program, so that you will never miss a payment and avoid annoying late fees. Below is further information about our payment plans: • Accounts become due on the 1st of the month; however your autopay may be processed on the 1st, the 10th, the 15th or the 25th of the month. • If no payment is received by the 28th of the month a $10 late fee is assessed, and a statement is sent to inform you of this balance (*statements are only sent to patients with a balance*). • At 60 days delinquent additional late fees will be applied. • The balance of the total treatment fee is due upon appliance removal, unless otherwise specified. If your autopay agreement is still in progress after braces are removed we will continue to process payments as agreed upon until the balance is paid. If we cannot successfully process your autopay we will contact you for updated payment information; however, if a payment is missed after appliances are removed your account may be sent to collections. • We understand that life happens, and so the primary goal of our collections system is to find a payment arrangement that will work for you and your family, even when circumstances change. We do not wish to dismiss patients from our practice; however, if you do not respond to our multiple requests for payment or work with us to rearrange your contract, we are left with no other option. If you transfer or move during the course of treatment your account will be prorated, and the account will be settled prior to sending your records to your new orthodontist.InsuranceOnce we verify and assign your orthodontic insurance benefit, an insurance ledger is established with the expected amount of insurance benefits. We will then be responsible to file your periodic insurance claims, accept payment and apply this to your account. Please be aware that many insurances do not pay your benefit in a lump sum, rather they send payment over the course of treatment. If the patient’s benefit decreases, changes or terminates, the unpaid balance is transferred back into the patient’s ledger and will be the responsibility of the patient.Assignment of Benefit AuthorizationI hereby authorize insurance payment directly to Franklin Orthodontics, PLLC, otherwise payable to me. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize this orthodontic office to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.Signature(Required) Date Month Day Year We love to celebrate the exciting moments of orthodontic treatment with our patients! This may include social media posts and photographs at special times, such as braces on or finishing treatment. If you would like to provide consent for these activities please sign below. Signature Date Month Day Year I have read the above document and understand the policies of Franklin Orthodontics, PLLC.Signature(Required) Date Month Day Year Privacy Policy and Release & WaiverYour Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your RightsYou have the right to: • Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your ChoicesYou have some choices in the way that we use and share information as we: • Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental health care • Market our services and sell your information • Raise fundsOur Uses and DisclosuresWe may use and share your information as we: • Treat you • Run our organization • Bill for your services • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actionsYour RightsWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.Your ChoicesFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation • Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information • Most sharing of psychotherapy notes In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and DisclosuresHow do we typically use or share your health information? We typically use or share your health information in the following ways.Treat you • We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization • We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services • We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues • We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research • We can use or share your information for health research. Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests • We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests • We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions • We can share health information about you in response to a court or administrative order, or in response to a subpoena.Our Responsibilities• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective date: 7/21/2020Release of Information(Required) I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Please read carefully(Required) I have read the above questions and understand them. I will not hold my orthondotist or any member of his/her 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 medical or dental health.
