What’s Important to You?

Patient Contact Information

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PRIMARY ORTHODONTIC INSURANCE
SECONDARY ORTHODONTIC INSURANCE

HEALTH HISTORY

MEDICAL HISTORY

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DENTAL HISTORY

Please circle if patient has or has had…
Any injuries to:

EMERGENCY CONTACT INFORMATION

By signing the following, I certify that all information listed above is correct and I grant permission to Dr. Jeffrey Mastroianni to take records for the purpose of making a proper diagnosis and treatment plan for the patient listed above. These records include a panorex, lateral cephalogram, digital photos, models of the patient’s teeth, and other diagnostic aids. I understand that it is not possible to begin orthodontic treatment without gathering all of the necessary records

Patient Disclosure Form

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In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual’s home.

Protecting Your Health Information:

I allow you to release my clinical and/or financial information to and/or answer questions from:

Communication Via Email:

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by authorized third parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount of protected health information in any communication.

I consent and accept the risk in receiving information via email. I understand I can withdraw my consent at any time. My email address is:

I do not consent to receive any clinical and/or information via email. I understand that I can change my mind and provide consent later.

Communication Via Text:

In order to enhance patient’s care and experience Amazing Smiles Orthodontics may contact you after your visit in order to request feedback on your experience by phone call, SMS text message, e-mail, voicemail, or mobile application, some of which may be via automated means. By signing below you understand and agree to be contacted in this manner with communication-related to this visit, any future visits. In the future, you may opt-out of receiving text messages by notifying us in writing (including responding via text message). Standard telephone minute and text charges may apply if we contact you.

PreviDent 5009 Booster Plus:
Overview:

PreviDent® 5000 Booster Plus is a fluoride toothpaste that is easily applied onto a toothbrush. This prescription toothpaste should be used once daily in place of your regular toothpaste unless otherwise instructed.

Dosage and Administration:

Patients 6 years of age or older, apply a thin ribbon of PreviDent® 5000 Booster Plus to a toothbrush. Brush teeth thoroughly once daily for two minutes, preferably at bedtime, in place of your regular toothpaste. For best results, do not eat, drink, or rinse for 30 minutes.

Preferred Pharmacy for Prescription Toothpaste:

Photo/Video Release:

For valuable consideration received, I hereby grant to Amazing Smiles and its legal representatives and assigns, the irrevocable and unrestricted right to use and publish video and/or photographs of me, or in which I may be included, for editorial, trade, advertising such as the Internet and/or Facebook and any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release the photographer and his/her legal representatives and assigns from all claims and liability relating to said photographs. (Please check the applicable box)

Relationship to Patient
Date:

Your Orthodontic Appointments

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In order to ensure quality orthodontic care, it is important that both parents and patients understand the manner in which we schedule your appointments. Our goal is to be the best part of your day and we make it a priority to value both you and your time. Therefore, we make every effort to stay on or ahead of schedule. lnconveniencing your work schedule and interrupting your child’s studies as infrequently as possible is very important to our entire office. Since the vast majority of our patients are of school age, it is unavoidable that some school-time appointments will be necessary.

We are glad to work around your child's important classes and provide your child with school excuses for scheduled orthodontic appointments. It is important for your child to turn these into the appropriate school official.

Our team works hard to provide the finest orthodontic care using the most convenient scheduling system possible for you and your child. Because we have families of our own, we understand your scheduling concerns and will do everything we can to ensure your child’s treatment goes as smoothly as possible.


  • LONG APPOINTMENTS, BANDING, AND BONDING: These are more detailed and technique- sensitive appointments. Therefore, these appointments will be scheduled during Doctor’s quiet time which is late morning and early afternoon.
  • ORTHODONTIC DISCOMFORT: (Pain, swelling, or bleeding) This usually results from trauma to the face or mouth. These patients will be seen as soon as possible and either appropriate care given or referral to another specialist provided for treatment.
  • REPAIRS: (Loose bands or brackets, broken archwires or ties, broken appliances or retainers) These appointments are always scheduled specifically during school hours since they are long visits. The vast majority of your appointments over the course of treatment will be short appointments. By seeing our long-visit patients during school hours, it leaves more room in our schedule to see patients during after-school hours.
  • Missed or Late-Cancelled Appointments: We kindly ask that cancellations be made at least 24 hours in advance to allow other patients to be seen in a timely manner. Appointments broken or not cancelled within 48 hours may incur a $25 fee. Another appointment will be scheduled; however, it may require a wait of four to six weeks. Appointments made during school hours may be arranged sooner. Repeated no-shows or late cancellations may result in dismissal from the practice.
  • GENERAL DENTIST APPOINTMENTS: As treatment progresses, it is important to continue seeing your regular dentist every six months for a checkup and cleaning.

Thank you so very much for understanding!

I have read and agree to the scheduling information above:

2220 S. State Route 157 • Suite 125 • Glen Carbon, IL 62034 • 618-288-0600
4905 Stone Falls Center Drive • Suite A • O'Fallon, IL 62226

AAOIC SUPPLEMENTAL INFORMED CONSENT

Orthodontic Treatment in the Era of COVID-19

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

HIPAA Notice of Privacy Practices

Effective Date: February 16, 2026

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Scope of Notice

This Notice of Privacy Practices ("Notice") applies to all Protected Health Information about you held or transmitted by Southern Orthodontic Partners ("we", "our", "us"). Protected Health Information is any individually identifiable health information about your past, present, or future physical or mental health condition or payment for healthcare or about the provision of care to you. Protected Health Information may include information about your condition or treatment, diagnostic tests and images, and related dental or other health information.

Our Responsibilities

We are required by law to maintain the privacy of Protected Health Information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

How We May Use and Disclose Your Protected Health Information

The following categories describe the different ways that we may use and disclose your Protected Health Information without an authorization. For all the following categories, when state or federal law (including the substance use disorder requirements at 42 CFR Part 2) is more restrictive, we are required to follow the more restrictive state applicable law. Not every use or disclosure in a category will be listed. Your Protected Health Information may be stored in paper, electronic or other form and may be disclosed electronically and by other methods:

Treatment. We may use and disclose your Protected Health Information for your treatment. For example, we may disclose your Protected Health Information to a specialist providing treatment to you.

Payment. We may use and disclose your Protected Health Information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain Protected Health Information.

Healthcare Operations. We may use and disclose your Protected Health Information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, arranging for legal services, conducting training programs, reviewing the competence and qualifications of healthcare professionals, and licensing activities. We may also use your Protected Health Information to notify you about our health-related products and services, to recommend possible treatment options or alternatives that may be of interest to you, to send you patient satisfaction surveys, or to send you appointment reminders. We may make incidental disclosures of limited Protected Health Information, such as by using sign-in sheets in our waiting rooms or calling out names in our waiting rooms when calling back patients for their appointments.

Business Associates. We may disclose your Protected Health Information to one or more of our service providers, known as "business associates," in order for them to provide services to us or on our behalf pursuant to a written business associate agreement. Our business associates are required to safeguard your Protected Health Information.

Health Information Exchanges. We may participate in one or more Health Information Exchanges (HIEs) and may electronically share your Protected Heath Information for treatment, payment, healthcare operations and other permitted purposes with other participants in the HIE. HIEs allow your health care providers to efficiently access and use your PHI as necessary for treatment and other lawful purposes.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your Protected Health Information to your family or friends, or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, if a person has the authority by law to make health care decisions for you, we may disclose information about you to such patient representative and treat that patient representative the same way we would treat you with respect to your Protected Health Information. We may also disclose your Protected Health Information to a public or private entity authorized by law to assist in disaster relief efforts to notify, or assist in notifying, a family member or personal representative about your location, general condition, or death.

Required by Law. We may use or disclose your Protected Health Information when we are required to do so by law, such as to report suspected abuse or neglect.

Public Health Activities. We may disclose your Protected Health Information for public health activities, such as to prevent or control disease, injury or disability, report child abuse or neglect, or notify a person of a recall, repair, or replacement of products or services.

Abuse, Neglect or Domestic Violence. If we reasonably believe that you are a victim of abuse, neglect, or domestic violence, we may disclose protected health information about you to a government authority, including a social service protective agency, authorized by law to receive reports of abuse, neglect or domestic violence.

Health Oversight Activities. We may disclose your Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure actions. For example, we may disclose Protected Health Information about you to the U.S. Department of Health and Human Services if it requests such information to determine that we are complying with federal privacy law.

Law Enforcement. We may disclose your Protected Health Information for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Judicial and Administrative Proceedings. We may disclose your Protected Health Information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Serious Threat to Health or Safety. We may disclose your Protected Health Information when permitted by law to avert a serious and imminent threat to the health or safety of a person or the public.

Specialized Government Functions. To the extent applicable, we may release your Protected Health Information for specialized government functions, including military and veterans activities, national security and intelligence activities, and correctional institutions.

Worker's Compensation. We may disclose your Protected Health Information to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Coroners, Medical Examiners, and Funeral Directors. We may release your Protected Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose your Protected Health Information to funeral directors consistent with applicable law to enable them to carry out their duties.

Research. We may use or disclose your Protected Health Information for research in limited circumstances, including when an institutional review board or privacy board has reviewed the research proposal and established a process to ensure the privacy of the requested information and approves the research.

Limited Data and De-identified Data. We may remove most information that identifies you from a set of data and use and disclose this data set for research, public health and healthcare operations, provided the recipients of the data set agree to keep it confidential. We may also de-identify your Protected Health Information and use and disclose the de-identified information for purposes permitted by law.

SUD Treatment Information. If we receive or maintain any information about you from a substance use disorder ("SUD") treatment program that is covered by 42 CFR Part 2 (a "Part 2 Program") through a general consent you provide to the Part 2 Program to use and disclose the SUD record for purposes of treatment, payment or health care operations, we may use and disclose your SUD record for treatment, payment and health care operations purposes as described in this Notice. If we receive or maintain your SUD record through specific consent you provide to us or another third party, we will use and disclose your SUD record only as expressly permitted by you in your consent as provided to us. In no event will we use or disclose your SUD record, or testimony that describes the information contained in your SUD record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested substance use disorder record is used or disclosed.

Other Uses and Disclosures of Protected Health Information

In any other situation not identified in this Notice, we will ask for your written authorization before using or disclosing information about you. Most uses and disclosures of Protected Health Information for marketing purposes and disclosures that constitute a sale of health information will be made only with your written authorization. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your Protected Health Information, except to the extent that we have already taken action in reliance on the authorization.

Your Protected Health Information Rights

Right to Access. You have the right to inspect and obtain copies of your Protected Health Information that we maintain or to direct us to send your Protected Health Information stored in an electronic health record to another person designated by you, with limited exceptions, as provided by 45 CFR § 164.524. You must make the request in writing at the address listed at the end of this Notice. In most cases, we will provide access to you or the person you designate within 30 days of your request. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. If you are denied a request for access, in certain circumstances you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Right to Request Amendment. You have a right to request that we amend your Protected Health Information if you believe the information is not accurate or is incomplete, as provided by 45 CFR § 164.526. To request an amendment of your health information, you must submit your request in writing to the address listed at the end of this Notice. Your request must explain why the information should be amended. We may deny your request under certain circumstances.

Right to an Accounting of Disclosures. You have a right to receive an accounting of certain disclosures of your Protected Health Information, as provided by 45 CFR § 164.528. To request an accounting of disclosures of your health information, you must submit your request in writing to the address listed at the end of this Notice.

Right to Request a Restriction. You have the right to request additional restrictions on certain uses and disclosures of your Protected Health Information for treatment, payment or healthcare operations, as provided by 45 CFR § 164.522(a). You must make your request in writing. We are not required to agree to your request, except we are required to agree in the case where your request is to restrict disclosures to a health plan for purposes of carrying out payment or healthcare operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Right to Alternative Communication. You have the right to request that we communicate with you about your Protected Health Information by alternative means or at alternative locations, as provided by 45 CFR § 164.522(b). You must make your request in writing. Your request must specify the alternative means or location and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have.

Right to a Paper Copy of this Notice. You have a right to obtain a paper copy of this Notice upon request.

Changes to this Notice

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all Protected Health Information that we maintain. When we make a material change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.