HEALTH HISTORY FORM

Joseph S Dietrich, DMD

Joseph S Dietrich DMD LLC / DBA Dietrich Orthodontics

PATIENT INFORMATION

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Middle

RESPONSIBLE PARTY INFORMATION

(Person responsible for paying the account)

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Middle
Marital Status
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I agree that the practice may communicate with me electronically at the email address above. I am aware that there is some level of risk that third parties may be able to read unencrypted emails. I am responsible for providing any updates to my email address. I may withdraw my consent at any time.

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PATIENT DENTAL INFORMATION

PATIENT MEDICAL INFORMATION

PATIENT GENERAL INFORMATION

EMERGENCY CONTACT

PHOTO PERMISSION

We offer many different contests and educational programs, along with before/after treatment photos that would allow you or your child to be a part of our social media, website, educational materials, and office postings. For your privacy, we do not include any last names on these photos and/or announcements. By signing below, I’m authorizing the practice to use the patient’s photo on all social media accounts, the website, and in the office. I hereby relinquish any and all rights to photographs, portraits, transparencies, negatives, prints, Polaroids, or other photographic reproductions captures with still, motion picture, video or other cameras for use by Joseph S Dietrich DMD LLC / DBA Dietrich Orthodontics.

ALL INFORMATION ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE:

Notice of Privacy Practices Acknowledgement & HIPAA Access Form

Dr. Joseph S Dietrich, DMD

Joseph S Dietrich DMD LLC / DBA Dietrich Orthodontics

Appendix 2.3.2 of HIPAA Policies

I have received a copy of this office’s Notice of Privacy Practices in accordance with HIPAA final rule.

* You May Refuse to Sign This Acknowledgment*

Access to Patient Account

Due to the HIPAA Privacy Rule, we must have permission for any other person to have access to the account/healthcare records.

Please list below the names of the people who are allowed access to the above named account, including yourself, biological parents, step-parents, grandparents, if applicable.

Please be aware that if this changes at any time during treatment, it is your responsibility to update our office.