We would like to welcome you and your child to our office. Our goal is to make your child’s visit
pleasant and educational.
We strive to teach good oral care that will enable your child 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
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
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 perform the necessary dental services my child may need.