Welcome to our office. Please allow us to get to know you better by completing the following questionnaire. Thank you.

Medical History: Do you, or have you ever had any of the following: Y= Yes, N= No, NA= Not Available (Please Specify)

Women Only

Kids Only

Allergies or reactions to any of the following:

Dental History

I have read, understood, the above questions and have answered to the best of my knowledge. I will not hold Mary Buatti Romeo, DDS, Karen Leavy, DDS, Scott Mateer, DDS, or Lindsay Alimena, DMD 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 inform this straight smiles.

Signed (Patient or Parent/guardian if minor) (Sign with mouse)



Orthodontics & Dentofacial Orthopedics for Children and Adults

(516) 541-9396
FAX: (516) 541-9510


*You may Refuse to Sign this Acknowledgement *


By signing this document you also acknowledge your orthodontic insurance claims are being filed electronically.


Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect:We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National security:We may disclose to military authorities the health information of Armed forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, comer intelligence, and other national security activities. We may disclose to the correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).


Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed a the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $ for each page, $ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in this format If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we are or our business associates disclosed your health information for purposes, other than treatment, payment, health care operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction:You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must your request in writing.) Your request must specify the alternative means of location, and provide satisfactory explanation of how payments will be hauled under the alternative means or location you request.

Amendment:You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice:If you receive the Notice on our Web Site or by electronic mail(e-mail), you are entitled to receive this Notice in written form.