Patient Biographical Information
Patient's Treatment Mindset
Responsible Party/Insurance Information
Please bring all of your insurance information to your first appointment.
I have read the above questions and understand them. I will not hold my orthodontist or any member 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 change in my medical or dental health.
HIPAA Notice of Privacy Practices
We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. Records made in the process of examinations, treatment, and retention may be used for purposes of consultations with other professionals, research, education, or publication in journals. In addition, we are required to safeguard patient information sent via email by using encrypted coding. This is to ensure the information within the message is read by the intended recipient only. If you would like to receive emails unencrypted, you have the right to request a change. Please be advised that by doing so may result in email interception by an unauthorized third party. All patient specific, treatment information emailed to your dentist or other dental professional will still be sent encrypted. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
- I consent to receive emails and text messages containing treatment information from OWOSSO Orthodontics unencrypted. I understand that this information may be susceptible to unauthorized third parties.