New Patient Form — Lotus Orthodontics and Periodontics

How this works: Fill out the form below, then tap Send form by email. It opens your email app with everything filled in, addressed to our office — just press Send. Nothing is submitted until you send that email. Please do not enter Social Security numbers or driver's license numbers here — we collect those in the office, not by email.

Patient Registration

First name

Last name

Middle initial

Preferred name

Birth date

Sex

Marital status

I would like to receive correspondence via email. Address Address 2

City

State

Zip

Home phone

Work phone

Cellular

Responsible party (if someone other than the patient)

First name

Last name

Middle initial

Address

City

State

Zip

Home phone

Work phone

Cellular

Birth date

Relationship to patient

Responsible party is also a policy holder for the patient.

Employment status

Student status

Employer

Emergency contact

Emergency contact phone

Referred by

Previous dentist

Preferred dentist

Preferred pharmacy

Preferred hygienist

Medicaid ID (if any)

Additional comments

Insurance Information

Primary insurance

Name of insured

Relationship to insured

Insured birth date

Employer

Insurance company

Insurance address

City

State

Zip

Remaining benefits

Remaining deductible

Secondary insurance

Name of insured

Relationship to insured

Insured birth date

Employer

Insurance company

Insurance address

City

State

Zip

Remaining benefits

Remaining deductible

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will receive.

Are you under a physician's care now?YesNo

If yes, please explain

Have you ever been hospitalized or had a major operation?YesNo

If yes, please explain

Have you ever had a serious head or neck injury?YesNo

If yes, please explain

Are you taking any medications, pills, or drugs?YesNo

If yes, please explain

Do you take, or have you taken, Phen-Fen or Redux?YesNo

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?YesNo

Are you on a special diet?YesNo

Do you use tobacco?YesNo

Do you use controlled substances?YesNo

Women

Pregnant / trying to get pregnant?YesNo

Taking oral contraceptives?YesNo

Nursing?YesNo

Are you allergic to any of the following? (check all that apply)

Other allergies — if yes, please explain

Do you have, or have you had, any of the following? (check all that apply)

Have you ever had any serious illness not listed above?YesNo

If yes, please explain Comments

Medications

Enter all prescription and over-the-counter medications you are currently taking. Do not list vitamins, other dietary supplements, or herbal medicines. Complete only the first four columns.

Name of medication	Dosage	Times a day	What is it taken for?

Patient Information and Agreement

Your first appointment will be an initial evaluation of your oral and general health.
Following today's appointment, the patient will receive radiographs (X-ray films) and further diagnostic procedures. A diagnostic fee will be charged. The patient's original X-ray films become part of Lotus Orthodontics and Periodontics' permanent records and will not be released. The patient or parent/guardian may request copies of clinical records, including X-ray films, by completing the appropriate forms and payment of a processing fee, determined by the number of X-ray films and pages copied. The doctor may utilize these records in photographic reports or scientific publications for advancement of dental teaching without revealing the patient's identity.
I give permission for the use of the following (initial below; I understand I can revoke this later in writing): (a) my photographs and X-rays in the before-and-after album; (b) my photographs on the webpages of www.DrFrankHsieh.com or bulletin board for demonstration purposes. No patient's name will be revealed anywhere on the website or bulletin board.
Patients who are late for appointments or have unpaid balances for treatment rendered may be rescheduled or dismissed as a patient of Lotus Orthodontics and Periodontics.
I understand that my children cannot be left unattended. They must be supervised by an adult.
I understand that a responsible parent or guardian can't leave the facility if the patient is a minor for all examinations and surgical appointments.
During the course of treatment, the doctor may deem that additional treatment of the patient is required and may be out of the scope of Lotus Orthodontics and Periodontics. An appropriate referral will be accomplished. Copies of X-ray films will be made available under the conditions previously described.
I consent to the acquisition, evaluation, and interpretation of necessary diagnostic information, including health questionnaire, extra-oral examination, intraoral examination, ordered dental radiographs, consultations from other health care providers, and other diagnostic procedures as deemed beneficial to patient assessment and diagnosis. I understand I will be informed of a plan of treatment, including possible risks and alternatives, prior to the beginning of dental care.
I understand I am financially responsible for all care received and agree to pay any charges not covered by a third party. Fees are charged for all services and must be paid at the time treatment is initiated. A $25.00 service fee will be charged for any payments made by check that is returned because of insufficient funds. If it becomes necessary to effect collections of any amount owed, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. Accounts assigned to collections will be charged a minimum of $25.00 collection fee or 40% of the amount owed, whichever is greater. If you choose to do an in-house payment plan, the Social Security number of the responsible party will be needed for a credit report.
For patients with dental insurance: I understand that if a pretreatment estimate is received from my insurance company, I will pay the estimated co-payment at the time each service is started; as a courtesy, my insurance company will be billed for the balance. If my insurance company does not pay within 60 days or if there is any balance after the insurance company's payment, Lotus Orthodontics and Periodontics will expect full payment from me. All accounts billed to patients are payable within 30 days of receiving a statement. There is a finance charge on any outstanding balance over 60 days from the date of treatment equal to 18% annually or 1.5% monthly. By signing below, I agree to accept responsibility for any unpaid balance after my insurance carrier has been billed. I understand that I am responsible for payment of all fees for treatment I or my dependents receive, and authorize release of any information relating to my dental claims. I hereby authorize payment of insurance benefits for my dependents and/or me to Lotus Orthodontics and Periodontics.
I have read the Patient Information and Patient Agreement forms. I agree to abide by the rules and regulations of Lotus Orthodontics and Periodontics and the conditions set out in the Patient Information and Patient Agreement forms.

I have read the above and agree to the Patient Information and Patient Agreement.

Initials for photo use (a) — before-and-after album

Initials for photo use (b) — website / bulletin board

Authorization for Release of Identifying Health Information

I authorize the professional office of my dentist to release health information identifying me, including if applicable information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services, to my dental and medical insurance companies, general dentist(s), and related dental and medical professionals, for treatment, payment, and health care operations.

I authorize the release described above.

Notice of Privacy Practices

Our full Notice of Privacy Practices is available on our website and in the office. By checking below you acknowledge you have received it.

I acknowledge I have received the Notice of Privacy Practices.

Signature

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status. Typing your name below counts as your signature on this emailed form.

Print patient name

Signature (type full name)

Date

Print parent/guardian name (if parent or guardian signed above)

If your email app doesn't open, use "Show form text to copy" and paste it into an email to DrHsieh@DrFrankHsieh.com yourself.