Orthodontic - New Patient Registration | Southern Smiles

New Patient Consultation Registration Form
(Orthodontics)

We require completion of this form prior to the doctor completing an initial exam.
For patients already in treatment seeking a 2nd opinion or seeking to transfer to our practice, we
have additional requirements and request that you to contact us first prior to completing this form.

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Patient Name: First Middle Last

Patient Date of Birth

Preferred Nickname

For children & college students, the patient’s current schooling is (skip if not applicable):

Public

Private

Homeschool

University / College

Name of School Patient Attends

Name of Adult Contact # 1 (adult patients enter your own name and information)

Mobile Phone Number For Adult Contact # 1

Email Address For Adult Contact # 1

Adult Contact # 1 Address (Street)

Adult Contact # 1 Address (City)

Adult Contact # 1 Address (Zipcode)

Adult Contact # 1 Address (State)

Name Adult Contact # 2 (optional 2nd parent / patient spouse / emergency contact)

Mobile Phone Number For Adult Contact # 2

Email Address For Adult Contact # 2

Adult Contact # 2 Address (Street) - If Different From Above

Adult Contact # 2 City - If Different From Above

Adult Contact # 2 Zipcode - If Different From Above

Adult Contact # 2 State - If Different From Above

List any other adults or family members (step parents, siblings, spouse, significant other) that we are permitted to work with during treatment.

Is there a custodial agreement that requires mutual consent for treatment?

Yes

Enter the name(s) of all who will be financially responsible for the patient

Are there family members who have already been seen by us?

Yes

DENTAL INSURANCE

In order to provide you with an accurate treatment cost and monthly payment plan for orthodontic
treatment, we require verifying orthodontic insurance coverage. We are not in network with NC
Medicaid for orthodontic treatment.

Please enter the information for the PRIMARY policy below. In the event there is secondary
insurance, we ask that you email us that information in advance as well. If you are uncertain about
which policy is primary and which is secondary, enter one policy below and email us the other
policy. Emailing a photograph of the front and back of the insurance cards is very helpful.
Email us at: referral@thetoothmover.com.

In the subject line please write: INSURANCE / PATIENT NAME / DOB.

Does the patient have orthodontic insurance coverage?

Yes

Unsure

Please enter the information for the policy below:

Subscriber Name

Subscriber DOB

Subscriber Address If Different From Patient

Subscriber ID

Subscriber SSN

Group #

Insurance Company

Provider Phone #

Employer

CURRENT DENTIST INFORMATION

Enter the name of patient’s family dentist (enter “none” if there is no current dentist)

We are required to verify that the patient is up to date with his / her dental exam and dental
cleaning with the family dentist.

Patients who are significantly over-due or do not have a current dentist are not eligible for active
orthodontic treatment.

Patients who are more than 12 months overdue should see their family dentist before scheduling
an orthodontic examination. In most circumstances, we are not permitted to begin orthodontic
treatment if the patient has dental work that still needs to be completed.

In the event that the last dental exam and cleaning was more than a year ago, delaying the
orthodontic exam until after the patient has seen the dentist is generally wise. In the event the
patient does not have a local family dentist, we are glad to help refer you to a local practice.

Type Of Examination / Consultation Interested In Check all that apply:

Orthodontic Exam & Treatment Consultation

Re-Treatment After Orthodontics (Teeth Have Shifted)

Replacement or Repair of Retainers

Replacement or Repair of Night Guard

TMJ / TMD Examination & Treatment Options

Orthodontics With Jaw Surgery Consult

Is there a history of trauma to primary / baby teeth? (If yes please provide details).

Is there a history of trauma to permanent adult teeth? (If yes please provide details).

Has the patient experienced injury to the face or jaws? (If yes please provide details).

Has the patient had jaw / orthognathic surgery in the past? (If yes please provide details).

Does the patient have anxiety about dental appointment appointments? (If yes please provide details).

Below are the most commonly used ways we align teeth for patients. Check all that the patient would consider or is interested in:

GENERAL MEDICAL HEALTH HISTORY

Is the patient in good health?

Yes

Bisphosphonates: Is there a history of taking Bisphosphonate drugs (ex. Fosamax) for treatment of osteoporosis or other bone disorders? (If yes please provide details).

Current Regular Prescription Medications If none, write “none” in comment box.

Please list any other allergies we should be aware of

Are antibiotics required prior to invasive dental procedures? (If yes please provide details).

Does the patient regularly or occasionally do any of the following? Check all that apply:

HEALTH CONDITIONS CHECK LIST

If the patient has a history of any of the following health conditions check the box next to the condition.

Any additional medical history comments or conditions:

Who may we thank for referring you to our practice? Check all that apply:

Is there someone specific we may send a thank you to?

Optional: You may upload images such as X-rays, a copy of the front and back of your dental insurance card, & any previous dental chart notes.

Upload Images

Upload Files

REVIEW & ACKNOWLEDGEMENT OF PRACTICE POLICIES

NEW PATIENT CONSULT APPOINTMENT CANCELLATION & RESCHEDULING POLICY To cancel your appointment, please notify our office at least twenty-four (24) hours in advance of your scheduled appointment time. Appointment changes can only be accepted during regular office hours. Less than twenty four hours advanced notice during regular business hours is considered a missed / no show appointment. Rescheduling a consultation appointment may incur a fee that is collected prior to rescheduling. PRIVACY DISCLOSURE STATEMENT & ACKNOWLEDGEMENT This section is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. It discloses to you how we normally operate and your acknowledgement thereof. The digital signature at the conclusion of this form does hereby signify that the undersigned does hereby attest to having been afforded the opportunity to review the Matthew David McNutt, DDS, MS, PA notice of privacy policy noted below. Patients / Parents / Guardians have the right to review our notice of privacy policy prior to signing this consent. You have the right to request restrictions on the use of your protected health information. We value protecting private patient information and have implemented layers of protection and staff training. This disclosure does serve notice that: Full initial examinations generally occur in a private consultation room. It is customary for patients upon arrival to use our digital check in device (iPad) to signify their arrival for a scheduled appointment, and this device does display the legal name of the patient. Our orthodontic treatment facilities operate with an ‘open-bay’ concept in the main clinic (no partitions or physical visual barriers between patient treatment chairs). This creates a fun and welcoming environment. Patients, their family members, and the staff will be present. Despite our best efforts to operate in a respectful and discrete manner, it is not possible within the practice to guarantee full privacy of all protected health information. A copy of the full privacy disclosure statement is available on our website and in office. POLICIES REGARDING FINANCIAL ARRANGEMENTS & INSURANCE BENEFITS Our practice has established Policies Regarding Financial Arrangements & Insurance Benefits for patient care provided by Matthew David McNutt, DDS, MS, PA. A copy of this document is available on our website and in office. The digital signature at the conclusion of this form does hereby signify that the undersigned has been informed of this and will be afforded the opportunity to review these policies prior to pursuing treatment with our practice. NEW PATIENT EXAMINATION EXPECTATIONS & FEES: Most of our new patient examinations are at no charge and others do incur a fee. This will vary depending on the type of exam and the circumstances. After reviewing the completed registration packet, our treatment coordinator will contact you in advance to discuss any examination fees prior to the scheduled consultation. The number of exams we schedule each day is considerably less than most orthodontic practices and is limited to 4-5. This is one reason for our careful screening process. We also limit the time of day we are willing to schedule new patient examinations. We realize that other offices may offer more convenient times as well. However, we understand that it is nearly impossible for an orthodontist to spend 20-30 minutes of quality time with 8-12 new patients a day, and still be hands-on with patients who are actively in treatment in the clinic. During the highly desirable early morning and after school hours Dr. McNutt is hands-on with his team, instead of delegating everything in order to see more new patient exams.

RELEASE FORM FOR MEDIA USE

We are passionate about creating a lifetime of healthy teeth and beautiful smiles. One of the best
ways to share our enthusiasm and educate people is to share images of our team having fun with
patients in the office and to share our work. We want to create positive and reassuring examples of
good oral health within the community. We often do this by sharing content we have created in the
office, on our website and social media. Images / video of patients may be a part of that media. We
treat the privilege of sharing our work with great respect.

Please select all of your preferences / permissions that apply below:

I hereby grant permission to use patient images and media obtained as described above to promote the practice and to promote good oral health within the community.

I also grant permission for our family to be ‘tagged’ on social media in conjunction with our posts.

I DO NOT grant permission to use patient images and media obtained as described above.

Please understand that you have the right to revoke permission or grant permission in the future as you see fit.

AUTHORIATION & DIGITAL SIGNATURE

CONSENT FOR NEW PATIENT EXAMINATION
The digital signature of the undersigned at the conclusion of this form does hereby grant and convey:

Consent to allow Dr. Matthew David McNutt, DDS, MS, PA to conduct an orthodontic examination of the aforementioned patient.
Understanding the examination will include diagnostic photographs (teeth and facial features).
Understanding that in order to complete at full exam we will usually need to evaluate a recent panoramic radiograph.
Consent to obtain a copy of the most recent panoramic radiograph (X-ray) from your family dentist.
Consent as necessary to obtain a new panoramic radiograph in our office the day of the examination, unless specifically prohibited by you at the exam, as is your right.
Understanding that in the event that permission to obtain diagnostic radiographs / X-rays is denied prior to, during and after treatment, the undersigned does hereby release the practice, practice ownership and doctor(s) from any responsibility related to the consequences of oral conditions possibly present that are not fully revealed or are undiagnosed as a result of opting out of dental radiographs.
Understanding that treatment options and estimated treatment fees may be discussed.

CONSENT TO RELEASE RECORDS & CORRESPOND WITH OTHER DOCTORS:
The digital signature at the conclusion of this form does hereby grant and convey permission to:

Release records to and correspond with the patient’s dentist of record.
Release records to and correspond with specialists for procedures related to the patient’s recommended treatment plan.

Furthermore, the undersigned does hereby attest to:

Having read, understood, and completed this registration packet accurately.
Understands and agrees to abide by the policies herein.
Grants or denies permissions as selected herein.
Furthermore, the undersigned is responsible for informing our practice of any changes to the patient’s contact information, changes in insurance and changes to medical status / history.
Having the authority to sign below.

Enter your full name below as your digital signature:

Your Signature

Date of Signature

McNutt Orthodontics
A DBA of Matthew David McNutt DDS, MS, P.A.

New Patient Consultation Registration Form (Orthodontics)

New Patient Consultation Registration Form
(Orthodontics)