ORTHODONTIC ACQUAINTANCE FORM - ADULT PATIENT
STREET ADDRESS
STREET ADDRESS LINE 2 EX: APT 2
CITY
STATE / PROVINCE
POSTAL / ZIP CODE
EX: DELTA DENTAL MI, BC/BS MISSOURI
FIRST & LAST NAME
AS IT APPEARS ON INSURANCE CARD - INCLUDE GROUP # IF PROVIDED ON INSURANCE CARD
I. DENTAL HISTORY
DENTIST NAME OR N/A
II. MEDICAL HISTORY
PHYSICIAN'S NAME OR N/A

HAVE YOU EVER BEEN DIAGNOSED WITH: (CHOOSE ALL THAT APPLY) *

OR LIST N/A
OR LIST N/A
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LAST
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PATIENT ACKNOWLEDGEMENT AND CONSENT FORM - HIPAA

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") required that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA's requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging to our professional competence; a review entitiy's functions; a claim for payment of fees; a third party payer's examination of our records; a court order as a part of a criminal investigation; an identification of a dead body; a lensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, email appointment reminders, x-rays, photographs or otherwise make disclosures of your information in connection with providing or coordination your treatment. There is some level of risk with unencrypted emails.

PATIENT ACKNOWLEDGEMENT

Please sign this form below, acknowledging that you have today received a copy of our Notice of Private Practices

Please sign this form below under the heading "Consent" to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.

Patient Signature (OR PARENT/GUARDIAN)

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RELEASE AUTHORIZING USE OF PERSONAL LIKENESS

I, and the patient for whose treatment I am the responsible party, consent to the use of my (or the patient’s) personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Dr. Blair White and the team at White Orthodontics, P.C. for any lawful use Dr. White deems appropriate, including for treatment, advertising his/her/its services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Dr. White during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.

I understand any image or likeness of me may be altered prior to use if deemed appropriate by Dr. White. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used.

I understand that Dr. White and White Orthodontics, P.C.will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that Dr. White cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that White Orthodontics, P.C. may use information regarding my health condition, including information regarding my diagnosis, course of treatment, my date of birth and/or age and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image of me.

I understand that White Orthodontics, P.C. may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.

I have read the foregoing in its entirety and understand its terms.

Patient Signature (OR PARENT/GUARDIAN)

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