UNDER 18 PATIENT FORM

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.

TELL US ABOUT YOUR CHILD

Last
First
Middle

RESPONSIBLE PARTY’S INFORMATION

City
State
Zip

DENTAL/ORTHODONTIC INSURANCE

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 perform the necessary dental services my child may need.

MEDICAL HISTORY

Now or in the past, has your child had:
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.
Has your child had allergies or reaction to any of the following:

DENTAL HISTORY

Now or in the past, has your child had:
Girls Only: