New Patient Registration & Health History
Company
Authorizations and consent
I consent to the use of electronic records and electronic signatures in place of written documents and handwritten signatures as described at
https://www.smilelogicortho.com/esign/
.
I authorize and consent to receive unencrypted email communication as described at
https://www.smilelogicortho.com/electronic-communication-authorization/
.
I have received or been offered a copy of the “Notice of Privacy Practices” to read at
https://www.smilelogicortho.com/hipaa-privacy-notice/
, and any questions I had were answered to my satisfaction.
I consent to an orthodontic evaluation by Bryon Viechnicki, DMD, MS (NJ Specialty Permit 6313).
Name of person signing on behalf of the patient *
Signer's relationship to patient
Today's date *
Patient health history
Patient name *
Patient date of birth *
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
Reason for visit *
Patient oral health history *
The patient has no history of pain in the jaw joints (TMJ), clicking of the jaw joints (TMJ), injury to the face or teeth, difficulty chewing, speech problems, pen, lip, or nail biting, thumb or finger sucking, grinding teeth (day or night), mouth breathing, snoring or sleep apnea, extra teeth, extraction of teeth, missing teeth, age-7 orthodontic checkup, and/or prior orthodontic treatment.
Significant oral health history
List the patient's significant oral health history *
Start typing and pick a suggestion, or just keep typing your own wording — you can edit any part. Separate multiple items with a period. Dictation and paste also work.
Patient medical history *
The patient has no history of allergy to acrylic, metal, or latex, allergy to medication, any hospitalization or surgery, arthritis, asthma, blood or bleeding disorder, diabetes, heart disease, high blood pressure, HIV+ or AIDS, liver disease, hepatitis, or jaundice, medication containing bisphosphonates, medication taken in past 7 days, rheumatic fever, seizures, thyroid disease, tobacco use, and/or tuberculosis.
Significant medical history
List the patient's significant medical history *
Start typing and pick a suggestion, or just keep typing your own wording — you can edit any part. Separate multiple items with a period. Dictation and paste also work.
Insurance benefits
There is no charge to you and no charge to your insurance for the orthodontic evaluation (D0140 Limited oral evaluation: problem-focused). We use your policy details to research your orthodontic insurance coverage. If treatment is recommended, payment plans are available for any portion of treatment your insurance does not cover. For details, please visit
https://www.smilelogicortho.com/orthodontic-insurance/
.
No orthodontic insurance
I authorize the release to my insurance company or companies any information, including the diagnostic records and diagnosis of any treatment required, to comply with applicable law and facilitate the billing and reimbursement for the treatment provided. I authorize payment be made to Smile Logic Orthodontics by my insurance carrier.
Insurance Carrier
Policy holder name
Policy holder date of birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
Policy holder's relationship to patient
Policy ID number
Policy group number
Responsible party information
Name of responsible party *
Relationship to patient *
State *
New Jersey
ZIP code *
City *
Street address *
Apartment, suite, unit (optional)
Email *
Phone number *
Radiographs
To reduce exposure to ionizing radiation, please request any available X-rays from your primary care dentist. Please send the X-rays to info@smilelogicortho.com.
If treatment is recommended, then we talk about getting braces and the investment involved. The way you tell us that you want to begin treatment is to book a 20 minute visit for detailed records at our office. The records are studied by Dr. Viechnicki to plan placement of braces, clear aligners, expanders, and retainers. The fee for records is $290 and includes an in-office Panoramic X-ray, Cephalometric X-ray, photographs, and digital impressions. Payment is due at the time you book the records appointment.
I will email X-rays to info@smilelogicortho.com prior to the 1
st
visit
I will bring printed X-rays to the 1
st
visit
I will not have X-rays evaluated at the 1
st
visit