Lovrovich Orthodontics Intake Form

Additional comments:

List current medication(s):

List allergies or sensitivities:

In regards to orthodontic treatment, please number in the order of importance from 1 to 4:

Quality:

Cost:

Discomfort:

Time:

I have completed this form to the best of my knowledge. I will report any changes regarding my dental or medical health to Dr. Lovrovich and/or staff as soon as possible.

Signature (patient/parent)

Date:

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT

We keep a record of dental healthcare services we provide you. You may ask to see and keep a copy of that record. You may also ask to correct the record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our Privacy Officer.

Our Notice of Privacy Practices describes in more detail how your dental information may be disclosed, and how you can access your information.

I acknowledge receipt of the Notice of Privacy Practices from Lovrovich Orthodontics, Anthony T. Lovrovich DDS., PS.

Patient of Legally Authorized Individual Signature:

Printed Name (or if signed on behalf of the patient):

Relationship:

(Parent, Legal Guardian, Personal Representative, Nanny)

Date:

Patient Information

RESPONSIBLE PARTY INFORMATION

Additional Information

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT