Forms

Name: Kirkpatrick & Lai Orthodontics
Address: 5304 S Harvard Ave, Tulsa, OK
Telephone: 918-747-1346
Price range: $
Rating: 99

Patient History

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Sex*
Age*
Birthdate*
Date Format: MM slash DD slash YYYY
Home Phone
Work Phone
Cell Phone*
School/Employer*
Grade/Position*
Father/Husband
Do you have contact information for the patient's father/huband?*
- Yes
- No
- Not Applicable
Father/Husband (Full Name)
First Last
Marital Status
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
School/Employer
Grade/Position
Cell Phone
Work Phone
Mother/Wife
Do you have contact information for the patient's mother/wife?
- Yes
- No
- Not Applicable
Mother/Wife (Full Name)
First Last
Marital Status
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
School/Employer
Grade/Position
Cell Phone
Work Phone
Siblings: Name & Age
Siblings: Name & Age
Siblings: Name & Age
How did you hear about our office?*
Responsible Party Email*
Patient Email (If Over 18)
Billing Information
Responsible Party Full Name*
First Last
Relation to Patient*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Signature of Responsible Party*
I certify the above information is true and correct to the best of my knowledge.
First Last
Signature

Medical History

Physician
Date of Last Visit
Date Format: DD slash MM slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you taking any medication? If so, which ones?*
Have you had any major operations?*
Have you ever been involved in a serious accident?*
Select any of the medical conditions below that you have had or currently have:*
Are there any medical conditions we have not discussed that you feel we should be made aware of?*
Signature of Responsible Party*
I certify the above information is true and correct to the best of my knowledge.
First Last
Signature

HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *Please Note: I may refuse to sign this acknowledgment. I have been offered and/or received a copy of Drs. Kirkpatrick and Lai's Notice of Privacy Practices. I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment from both myself and/or third party. I understand that I may request a copy of the privacy policies at any time.*
Printed Patient Name:
Date
Date Format: MM slash DD slash YYYY
Patient Signature (18+ years of age)
Patient Signature (18+ years of age)
Parent/Guardian Signature*
Parent/Guardian Signature*
Relationship to Patient*

Name and relationship for each person to whom you authorize release of information to:

Expires 3 Years from Initial Signature*
Date:
Date Format: DD slash MM slash YYYY
Expires when patient reaches the age of 18*
Date of Age 18:
Date Format: DD slash MM slash YYYY

Insurance Form

Primary Policyholder/Subscriber Information
Policyholder/Subscriber Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Policyholder ID/SSN*
Insurance Company*
Plan/Group Number*
Employer Name*
Change of Insurance
- New Plan
- New Employer
Do you have Secondary Insurance?*
- Yes
- No
Secondary Policyholder/Subscriber Information
Policyholder/Subscriber Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Policyholder ID/SSN*
Insurance Company*
Plan/Group Number*
Change of Insurance
- New Plan
- New Employer
Employer Name*
Patient Information
Relationship to Policyholder/Subscriber*
Patient Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
Authorizations
I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.*
Parent/Guardian Name
Signature
Date*
Date Format: MM slash DD slash YYYY
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.*
Parent/Guardian Name
Signature
Date*
Date Format: MM slash DD slash YYYY

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Forms

Patient History

Father/Husband

Mother/Wife

Billing Information

Dental / Medical History

Dental History

Medical History

Medical History

HIPAA

Insurance Form

Primary Policyholder/Subscriber Information

Secondary Policyholder/Subscriber Information

Patient Information

Authorizations

Hewlett HealthChoice Enterprise

HealthChoice & EDS Form