Patient Health History Form

Patient Name

Date

E-mail:

Patient's Birthdate

Family Dentist

Family Physician

Please check all that apply

Dental History

Yes

Medical History

Has patient had or have any of the following?

Yes

Please inform us if any changes occur to the patient's medical history.

Patient Information

* Date

Patient's Name

* Last Name

* First Name

* Middle Name

Address

* Street

* City

* State

* Zip

* Home Phone

* Birthdate

Social Security #

* If patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office?

Responsible Party Information

Name

* Last Name

* First Name

* Middle Name

* Marital Status

Residence

* Street

* City

* State

* Zip

Mailing Address

* Street

* City

* State

* Zip

* How long at this address?

* Home Ownership? Rent Own Other

* Home Phone

* Work Phone

Previous Address (if less than 3 yrs.)

Street

City

State

Zip

* Social Security #

* Birthdate

* Relationship to Patient

* Employer

* Occupation

* No. Years Employed

Spouse's Name

* Last Name

* First Name

* Middle Name

* Relationship to Patient

* Employer

* Occupation

* No. Years Employed

* Social Security #

* Birthdate

* Work Phone

Insurance Information

Insured's Name

Insured's Soc. Sec. #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Do you have dual Coverage? Yes No

If yes:

Insured's Name

Insured's Soc. Sec. #

Insurance Co.

Group No.

Local No.

Insurance Co. Address

Authorization - Assignment of Benefits

Emergency Information

* Name of nearest relative not living with you

* Complete Address

* Phone

I understand that where appropriate, credit bureau reports may be obtained.

* Signature (Parent's signature if minor)

Updated (date & initial)

Authorization to Release Orthodontic Needs

Rosenthall Orthodontics is dedicated to our patients. Our goal is to give our patients the best possible treatment with the least inconvenience, using the most advanced treatment techniques and materials. We strive to exceed our patient's expectations in every aspect of their orthodontic treatment.

Patient's Name

Date of Birth

It is the policy of our office not to release patient information about you or your child unless it is for patient care and treatment or payment. Our office is an open bay concept. We try, to the best of our ability, to keep the discussion of patient information to a minimum. If you wish for Dr. Rosenthall and/or office staff to leave messages for you on your home telephone, message number, answering machine, work telephone, voice mail, cell phone or pager, or to any other person, then you must sign the following:

I authorize the release of appointment confirmations through text messaging which can be unsubscribed at any time.

Please provide the phone number you wish to subscribe text messaging with:

I authorize Mark R. Rosenthall, DDS, MSD or staff to release patient information about me/my child and agree it is my responsibility to notify the staff whenever I want this to change.

Patient/Guardian Signature

Date

Witness

Date

You may also disclose information to my family members and non-family members listed by name and relationship.

Name

Relationship

Name

Relationship