Tell Us About Yourself

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Please fill out this form completely to the best of your ability. The better we communicate, the better we can care for you. All patient records are kept strictly confidential

In the event of an emergency, who should we contact?

Primary Orthodontic Insurance

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Medical History

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Medical History continued

Have you ever had any of the following medical problems?
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Dental History

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent. I understand that I am responsible for full payment of services rendered and also responsible for paying any co-payments and deductibles that my insurance does not cover.

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

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I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein.

Privacy Consent and Email Authorization

This form is optional under the U.S. Department of Health and Human Services patient privacy regulations.

Your protected health information such as name, address, dates, phone/fax numbers, email and social security numbers may be used in connection with your treatment, payments on your account, or health care operations. You may revoke your consent, in writing, at any time.

All insurance electronic claims are done with encryption through a secure website.

At times we may need to communicate with you, your dentist and other health care providers via email. By signing this form you give Cohen Orthodontics permission to communicate with you and your health care providers and insurance providers via email or other electronic means, without encryption or special security precautions, which may be accessed by a third party while in transit. The patient information that may be emailed may include x-rays, photos, health history, diagnosis, treatment, and payment records. Cohen Orthodontics DOES NOT email sensitive personal information such as social security numbers, credit card numbers, mental health diagnosis, genetic information etc.

You can tell us in writing to stop emailing your patient information at any time. This will not affect emails that Cohen Orthodontics already sent before receiving your written instructions to stop.