Patient Forms

We’re looking forward to meeting you on your first visit to Hollywood!! To make things easier for you, fill out your health history forms online to save you time on your appointment day. They will be automatically e-mailed to our office.

• • Online Health History Form
  • Covid-19 Informed Consent Form

OR If you prefer to print the forms and fill them out ahead of time and bring them to your appointment, you may do that as well.

• Health History Form (Child) PDF
• Health History Form (Adult) PDF

If you’re unable to open PDF files, you can get Adobe Reader® for free.

Click here to schedule your FREE Smiles Hollywood Orthodontics evaluation, or call (972) 529-9700 to speak with someone on our dynamic team!

Schedule an Appointment

The online Health History form needs to be filled out in its entirety. Please do not skip any questions or leave anything blank. All of it is very important to us! It starts by asking for the patient’s basic Top Mckinney Orthodontics information, such as name, date of birth, and address. It also asks for the name and ages of other children and/or siblings. Of course, please let us know if one or more of the siblings is already in treatment with us! We love having multiple family members as our patients! This form also asks how you heard about our office! This form is significantly important to us because we like to know where our patients are coming from so that we have the opportunity to thank anyone who has referred you to us! So, please let us know if you saw us in a publication, online, if one of your friends is a patient here (we love referrals from our current and past patients!) or if you saw Dr. Crise at a local school visit!

Next, we ask for a Medical History form. Please check Yes or No next to each question. All of this information is very important so we know if extra care needs to be taken with a patient, especially if a medical condition exists. For example, suppose a patient has a heart murmur or defect. In that case, we need to know that Top Mckinney Orthodontics information because we will need a note from their cardiologist as to whether or not they need to be premedicated before each of their orthodontic appointments. We are happy to call in pre-meds for you during your appointments if needed. Of course, we also need to know if you have allergies to anything at all. Some people are allergic to latex, so we have special latex-free gloves that our doctors will wear for those patients who are allergic to latex!

Please also remember to give us your email address, phone number, etc. We also ask for your spouse’s information as well (if you are married). We need the spouse’s information because your orthodontic insurance is often listed under your husband’s information, so we do need their information as well.

The next section asks about your insurance information. We know that most insurance companies do not send out dental cards anymore. This makes it a bit more difficult for everyone to obtain this information. Still, we need your dental information to verify your insurance to see if you have any Top Mckinney Orthodontics coverage. Please give us all the information you can on the insurance section so we can find your coverage for you. We will need the subscriber’s name, employer, date of birth, social security number, group number, and ID number. It is also excellent if you could provide us with the phone number of your dental insurance carrier. We always try to verify all of your orthodontic coverage before you come into the office to save you time, which is why it is so critical that you fill out all of your forms before you arrive for your visit. Our staff can often be on hold with an insurance company for an hour or more in order to verify your benefits, so let us do this footwork for you! Also, just a side note on orthodontic insurance coverage, it is very different from medical and dental insurance in that usually, it is a one-time lifetime maximum per patient. For example, if you have $1500 in Top Mckinney Orthodontics coverage, that is the total amount you have for the patient’s lifetime unless the subscriber takes a new job and gets more coverage then.

Next, we ask that you sign the authorization forms stating that the insurance carrier can release benefit information to us.

Then, there is our HIPAA form that ensures your privacy. The HIPAA form states that we will not release any information to anyone outside medical, dental, or insurance company personnel unless you tell us to.

The Photo/Video Release form allows our doctors to show your image for teachings and scientific meetings or conferences. Please check yes or no on this page and then sign and date it. We love to showcase some of our awesome patients in advertising or marketing materials. From time to time, we may publish a short video clip on our website or in a short YouTube video compilation. We would love to feature you or your child in some of these Top Mckinney Orthodontics publications if you are okay with it. We will never use your last name on social media.

The Covid-19 Informed Consent Form must be filled out on THE DAY OF YOUR APPOINTMENT, so please wait to fill them out! This form not only protects the Top Mckinney Orthodontics staff at Smiles Hollywood Orthodontics from ill people entering our office, but it also allows you, as the patient, to know we are taking every precaution possible to protect our patients from COVID-19. Please carefully answer each of the questions on the form, and please call us ahead of time to reschedule your appointment if you think your child could be ill or if they have been exposed to COVID-19. We would rather be overly cautious than expose others.

Click here to schedule your FREE Smiles Hollywood Orthodontics evaluation, or call (972) 529-9700 to speak with someone on our dynamic team!

Schedule An Appointment