Health-History-Child-Form

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING PROVIDERS/ FACILITIES IN THE FUTURE.

Please print your name:

Please sign your name

If Patient is a minor:

Parent/Guardian name (please print):

Parent/Guardian (please sign your name)

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name:

Relationship:

Name:

Relationship:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

She has two children: her daughter, Inga, and her son, Benjamin.
She likes to travel, exercise, do art projects and spend time with her family.
She was in softball, gymnastics and track as a child and teenager.
She once played Rugby in college.
Her favorite foods are oysters, avocados and cheese (not necessarily together, though!)
Her family has a cat named Smokey and a dog named Soldier.
Her best friends are her husband, Abram, and her sister, Kendall.
She’s had orthodontics too! She wore headgear at age 9 and braces from ages 11-13.
She has the largest private Dr. Seuss art collection in the state of Colorado! (Look around you)

Now tell Dr. Sloss something about you...

My name is

You can call me

I have

brother(s) and

sister(s).

Their names are

I have

dog(s) and

cat(s) named

My favorite things to do

My favorite sports

My favorite foods

My favorite music

My favorite book

How I feel about getting braces or clear aligners

CHILD HEALTH HISTORY

About Your Child

Billing Party

Orthodontic Insurance Information

Medical History

Dental History

Authorizations

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

Now tell Dr. Sloss something about you...