• Orthodontic Acquaintance Form

    Orthodontic Acquaintance Form

    Child
  • Which of the follow are MOST important to you in choosing an orthodontic home (select the top 2-3 that apply)?*
  • Which description best matches your approach to healthcare communication and decision making?*

  • Patient Information

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  • Child's preferred pronouns
  • Is your child adopted?

  • Household Information

  • Does your child reside with you full time?*
  • Additional Parents/ Guardians*
  • Format: (000) 000-0000.
  • Parent/Guardian (1) Marital Status:*
  • Parent/Guardian (2) Marital Status:*

  • Dental History

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  • Is there dental work yet to be completed (fillings, crowns, etc.)?*
  • How often does your child brush their teeth?*
  • Does your child grind their teeth?*
  • Does your child suck thumb/finger?*
  • Has your child had previous orthodontic consultations or treatment?*
  • Does your child's water supply contain fluoride?*
  • Does your child require antibiotic premedication (antibiotic prophylaxis,) for routine dental procedures?
  • Have your child's tonsils and/or adenoids been removed?*
  • Is your child excited about potentially starting treatment?*

  • Insurance Information

  • Does your child have orthodontic coverage on a dental insurance plan?*
  • Does your child have secondary orthodontic coverage on a dental insurance plan?*
  • Is your child covered under 3 or more insurances?

  • Medical History

  • Is your child currently taking any medications (including over the counter)?
  • Does your child have any allergies or sensitivities?
  • Has your child started her menstrual cycle (we use this question to help determine growth trajectory)?*
  • Has your child ever been diagnosed with:*
  • Has a sleep study (Polysomnography) been performed on the patient in the past?*

  • Sleep Apnea Questionnaire

    Please answer the following questions based on events that occurred in the last month. Dr. White asks that you complete this form (for the child patient) as accurately and honestly as possible. We are interested in overall health, not simply teeth alone. Orthodontic treatment can be an integral part of managing health problems related to sleep and breathing disorders.
  • Snore more than half the time?*
  • Has a teacher or supervisor commented that your child appears tired during the day?*
  • Always snore?*
  • Snore loudly?*
  • Has 'heavy' breathing, or struggles to breathe?*
  • Has difficulty staying awake during the day?*
  • Seems to "space out" during conversations?*
  • Is "on the go" or often acts as if "driven by a motor?"*
  • Wakes up with headaches in the morning?*
  • Is easily distracted by extraneous stimuli?*
  • Overweight?*
  • Fidgets with hands or feet, or squirms when sitting?*
  • Has difficulty organizing tasks or duties?*
  • Interrupts or intrudes on others (butting in on conversations?)*
  • Is hard to wake up in the mornings?*
  • Occasionally wets the bed?*
  • Has ever stopped breathing during the night?*
  • Has a dry mouth in the morning?*
  • Wakes up unrefreshed?*
  • Did your child stop growing at a normal rate at any time since birth?*
  • Tends to breathe through the mouth during the day?*

  • 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.

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  • 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.

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