Dr. Farrah Ortho
Medical History Form

Dentist Information:

Who is Financially Responsible for This Account?

Orthodontic Insurance Information:

*For the following questions Mark Yes, No, or Don’t Know/Understand (DK/U). The answers are for our office records and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

PATIENT PROFILE

Medical History

*Now or In the Past, Has The Patient Had:
Please Name Them:

Girls Only

Allergies or reactions to any of the following:

DENTAL HISTORY:

*Now or In the Past, Has The Patient Had:

I have read and understand the above questions. 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. If there are any changes later to this history record or medical/dental status, I will so inform this practice.

Signed:
Signed:

Notice of Health Information Practices
Acknowledgement Form Dr. Farrah Ortho

The attached notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please sign this cover sheet acknowledging receipt of the policy and return it to the receptionist. Review the policy carefully and lets us know if you have any questions or requests.

By my signature below, I acknowledge that I have received the Notice of Health Information Practices of Dr. Farrah Ortho. I understand that the organization reserves the rights to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this content in writing, except to the extent that the organization has already taken action in reliance thereon.

Our office attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained for the following reasons: