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KEITH T. SELLERS, D.D.S., M.S.

Orthodontic Acquaintance Form

Child Patient Information

Street
City
State
Zip

Responsible Party Information

Have we previously treated any family members?

Are you nervous or anxious about dental treatment?

How did you hear about us?

Responsible Party Signature

MEDICAL HISTORY

DENTAL HISTORY

Sellers Orthodontics

Authorization for Release of Information - Compound Release

Sellers Orthodontics is authorized to release protected health information about the above named patient in the following manner and to identified persons.

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

*For email communication to occur, please accept the disclosure below:

*For text communication to occur, accept the disclosure below:

Patient Rights:

  • I have the right to revoke this authorization at any time.
  • I may inspect or copy the protected health information to be disclosed as described in this document.
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
  • I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

Signature of Patient or Personal Representative

*Description of Personal Representative's Authority (attach necessary documentation)

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ORTHODONTIC INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION ONLY PLEASE

We will be happy to assist you in determining your orthodontic insurance benefits, however all information must be completed and signed.

I hereby authorize release of any information relating to this claim

Signature of insured party

I hereby authorize payment directly to Dr. Sellers

Signature of insured party

I do not have Dental Coverage

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.