A beautiful smile is a wonderful asset. Please fill out this form completely.
The better we communicate, the better we can care for you.
understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographics) may be used or disclosed by us, electronically or physically, in one or more of the following respects:
Under the new privacy rules, you have the right to
Spring Orthodontics would like your permission to use facial images taken of you/your child/children to increase community awareness of our practice and showcase extraordinary before and after smiles on our website and social media outlets.
Please indicate below the following areas where you consent to the use of your/your child’s/children’s facial picture(s).