We would like to welcome you to our office. Our goal is to make
your visit pleasant and educational. We strive to teachgood
oral care that will enable you to have a beautiful smile that
lasts a lifetime.
Release of Records I hereby
authorize Ashburn Orthodontics to provide other health care
providers and medical and dental insurance companies with
information regarding the above individual’s orthodontic care as
deemed appropriate. I understand that once released the above
doctor and staff have no responsibility for any further release by
the individual receiving this information. Such records may
include medical care and treatment, illness, or injury, dental
history, medical history, consultation, prescription, x-rays,
models, and copies of all dental and medical records. I agree to
pay for the cost of duplicating any records. A photocopy or scan
of this release will be as effective and valid as the original.
HIPPA Notice We are required
by law to maintain the privacy of and provide individuals with the
HIPPA notice of our legal duties and privacy practices with
respect to protected health information. If you have any
objections to the HIPPA notice, please ask to speak with your
HIPPA compliance officer in person or by phone at our main phone
number. Signature below is the acknowledgment that I have received
the HIPPA Notice of our Privacy Practice.
Release and Waiver I have
read the above questions and understand them. I will not hold my
orthodontist or any members of his/her staff responsible for any
errors or omissions that I have made in the completion of this
form. I will notify my orthodontist of any changes in my child’s
medical or dental health. I authorize the dental staff to per form
the necessary dental services my child may need.