Health History |

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Health History

Submit Your Health History Online

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.
Patient Information
Which office location will you be visiting?*
- First Name*
  First
- Middle Name
  Middle
- Last Name*
  Last
- Gender*
  - Male
  - Female
- Date of Birth*
Address*
Street Address Address Line 2 City State ZIP / Postal Code
- Phone
- Cell Phone*
Email*
Responsible Party Information
Responsible Party*
- Self
- Father
- Mother
- Spouse
- Other
- First Name*
  First
- Middle Name
  Middle
- Last Name*
  Last
Address*
Street Address Address Line 2 City State ZIP / Postal Code
- Phone
- Work Phone
- Cell Phone*
- Email*
- Date of Birth*
- Marital Status*
- Does this person live in the same household as the patient?*
- S.S. #*
- Emergency Contact*
- Emergency Contact Phone*
Responsible Party Employer Information
Employer Name*
Address
Street Address Address Line 2 City State ZIP / Postal Code
- No. Years Employed
- Occupation
Insurance Company Name
Address
Street Address Address Line 2 City State ZIP / Postal Code
- Phone
- Phone Extension
- Group #
- Policy #
Orthodontic Coverage?
- Yes
- No
- Not Sure
Second Responsible Party Information
Is There a Second Responsible Party?
- Yes
- No
Responsible Party*
- Father
- Mother
- Spouse
- Other
- First Name*
  First
- Middle Name
  Middle
Last Name*
Last
Address*
Street Address Address Line 2 City State ZIP / Postal Code
- Phone
- Work Phone
- Cell Phone
- Email
- Date of Birth*
- Marital Status*
- Does this person live in the same household as the patient?*
- S.S. #*
- Emergency Contact*
- Emergency Contact Phone*
2nd Responsible Party Employer Information
Employer Name
Address
Street Address Address Line 2 City State ZIP / Postal Code
- No. Years Employed
- Occupation
Insurance Company Name
Address
Street Address Address Line 2 City State ZIP / Postal Code
- Phone
- Phone Extension
- Group #
- Policy #
Orthodontic Coverage?
- Yes
- No
- Not Sure
Other Information
- Dentist Name
- Who may we thank for referring you to our office?
Do you have other children?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Add additional child?
- Yes
- No
- Child's Name
- Age
Medical Information
- Any heart disease?*
  - Yes
  - No
- Any respiratory disease?*
  - Yes
  - No
- Any blood disease?*
  - Yes
  - No
- H.I.V Positive?*
  - Yes
  - No
- Any bone disease?*
  - Yes
  - No
- Any prolonged bleeding?*
  - Yes
  - No
- Does the patient bruise easily?
  - Yes
  - No
- Is patient under medical care?*
  - Yes
  - No
- Any nervous/emotional problems?*
  - Yes
  - No
- Any drug addiction?*
  - Yes
  - No
- Is the patient pregnant at this time?*
  - Yes
  - No
- Hepatitis?*
  - Yes
  - No
- Epilepsy/seizures?*
  - Yes
  - No
- Latex allergy?*
  - Yes
  - No
- Chemical dependence?*
  - Yes
  - No
- Any liver disease?*
  - Yes
  - No
- Any condition needing MRI follow-up?*
  - Yes
  - No
Explain any "yes" answers
List any allergies
List any medications the patient is taking
List any problems not mentioned above that we should know about
Dental History
- Has the patient seen a general dentist in the last year?*
  - Yes
  - No
- Any pain, clicking, or discomfort in or near the patient's ears?*
  - Yes
  - No
- Does the patient have any "gum" problems?*
  - Yes
  - No
- Cheek, tongue, or lip chewing?*
  - Yes
  - No
- Thumb sucking*
  - Yes
  - No
- Tongue thrusting*
  - Yes
  - No
- Grind teeth*
  - Yes
  - No
- Speech problems*
  - Yes
  - No
- Ever been examined by an orthodontist before?*
  - Yes
  - No
- When?
- Have other members of the family had orthodontic treatment?*
  - Yes
  - No
In your own words, what is the orthodontic problem?*
What would you like orthodontic treatment to accomplish?*
TCPA
In order for us to send text appointment reminders the Telephone Consumer Protection Act (TCP) enacted by the Federal Communications Commission (FCC) requires a signature from you to receive automated phone calls from the office of:

Dr. J. Matthew Elison @ Elison and Wood Orthodontics
Dr. Ryan L. Wood @ Elison and Wood Orthodontics

"I,
Name*
First Last
, hereby consent to receive autodialed and/or pre-recorded appointment reminder calls and recall reminder calls from/or on behalf of Dr. J. Matthew Elison @ Elison and Wood Orthodontics and Ryan L. Wood @ Elison and Wood Orthodontics at the telephone number(s) provided"

I understand that consent is not a condition of services
Effective October 16, 2013
- Home phone number
- Father's CELL phone number
- Mother's CELL phone number
- Mother's WORK phone number
- Father's WORK phone number
Enter the Preferred number for your automated messages*
Email address
Names of patient(s) in treatment
- Name
  First Last
- Name
  First Last
- Name
  First Last
- Name
  First Last
- Name
  First Last
- Name
  First Last
Privacy Consent
This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office's privacy notice prior to signing this Consent, a copy of which was given to you with this Consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.

Thank you for your cooperation. Please let us know if you have any questions.
- Patient / Parent / Guardian's Signature*
- Date*
  MM slash DD slash YYYY

Idaho Falls

3357 Merlin Drive
Idaho Falls, ID 83404
Phone : 208-522-9600

Rigby

711 Rigby Lake Dr. Suite 100
Rigby, ID 83442
Phone : 208-522-9600

© 2018 Elison Orthodontics
All rights reserved.

Rexburg

214 E. 1st N.
Rexburg, ID 83440
Phone : 208-356-3300

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