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CONFIDENTIAL

Medical Dental History Form for Adult Patients

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Signature

Signature

PRIVACY CONSENT

  • This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.
  • Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used win connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).
  • You have the right to review our office’s privacy notice prior to signing this Consent, a copy of which was given to you with this Consent.
  • You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.
  • We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.
  • You may revoke this Consent at any time in writing. However, such a revocation will not be effective to the extent that any action has been taken in reliance on this Consent.
  • Thank you for your cooperation. Please let us know if you have any questions.

Patient’s Signature