Child Acquaintance Form

Insurance Information
Does your child have orthodontic coverage on a dental insurance plan?*

YesNoUnsure
Subscriber's Full Name:*
As it appears on your insurance card.
Subscriber's Date of Birth:*
MM/DD/YYYY
Subscriber's Employer:*
As it appears on your insurance card.
Insurance Company and State:*
Example: Delta Dental of Michigan
Insurance ID Number (or SSN:)*
Providing subscriber's social security number (SSN) if you cannot find the insurance ID number helps verify your insurance before you arrive to give you a better idea of what and how much of orthodontic treatment is covered. This could help lower your total investment. This is protected health information and will not be included in notification & autoresponder emails and messages.
Insurance Group Number:*
As it appears on your insurance card.
Does your child have secondary orthodontic coverage on a dental insurance plan?*

YesNoUnsure
Subscriber's Full Name:*
As it appears on your insurance card.
Subscriber's Date of Birth:*
MM/DD/YYYY
Subscriber's Employer:*
As it appears on your insurance card.
Insurance Company and State:*
Example: Delta Dental of Michigan
Insurance ID Number (or SSN:)*
Providing subscriber's social security number (SSN) if you cannot find the insurance ID number helps verify your insurance before you arrive to give you a better idea of what and how much of orthodontic treatment is covered. This could help lower your total investment. This is protected health information and will not be included in notification & autoresponder emails and messages.
Insurance Group Number:*
As it appears on your insurance card.

HIPAA (Health Insurance Portability and Accountability Act)

Patient Acknowledgement and Consent
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.
Parent/Guardian Signature:*

Clear
Parent/Guardian full name:*

FIRSTLAST
Today's date:*

MonthDayYear
MM/DD/YYYY

Personal Likeness Consent

Social Media Consent Form
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 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 unforseen event my image or likeness is used by third parties.

I understand and agree that White Orthodontics, P.C. may use information regarding my course of treatment 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.
We respect your privacy. If you prefer to opt out of marketing and likeness, please click the box here and do not sign below. Thank you!

Opt out of personal likeness
Parent/Guardian Signature:

Clear
Parent/Guardian Name:

FIRSTLAST
Today's Date:*

MonthDayYear
MM/DD/YYYY
Should be Empty:

Orthodontic Acquaintance Form

Patient Information

Household Information

Insurance Information

Dental History

Medical History

Sleep Apnea Questionnaire

HIPAA (Health Insurance Portability and Accountability Act)

Personal Likeness Consent