CHILD PATIENT
INFORMATION

GETTING TO KNOW YOUR CHILD...

WHAT ARE YOUR GOALS?

DENTAL INSURANCE INFORMATION

EMERGENCY INFORMATION

MOTHER'S INFORMATION

FATHER'S INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

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PEDIATRIC SLEEP QUESTIONNAIRE

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NOTICE OF PRIVACY PRACTICES (HIPAA)

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.

  • To other health care providers (i.e. your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e. to determine the results of cleanings, surgery, etc.)
  • To third party payers or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e. to determine benefits, dates of payment, etc.)
  • To certifying, licensing and accrediting bodies (i.e. American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation.
  • Internally, to all staff members who have any role in your treatment
  • To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
  • To your family and close friends involved in your treatment
  • To contact you in order to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
  • To email your x-rays, photos, and treatment plan to your other doctors as needed.
  • To leave messages or email you regarding upcoming appointments.

Your Rights Regarding Your Health Information

Acknowledgments and Permissions

Please check all that you are acknowledging and granting permission!