Thank you for choosing an orthodontic specialists. We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

 

Who Is Accompanying The Child Today?

Parent's Information

Does/did the Child Have Any of the Following?

Has your child ever had any ofthe following medical problems:

I understand that the information that I have given is correct to the best of my knowledge, that is will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of parent or guardian Date

This office reserves the right to verify the credit status of potential patients and/or prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting agencies.

Signature of parent or guardian Date

The Parent or Guardian who accompanies the child is responsible for payment at times of service unless prior arrangements have been made. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDA and the ADA.

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

 

Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully. This information is made available upon request by a patient.

We understand that your dental health information is personal and we are committed to protecting any information about you. As our patient, we create dental records about your dental health, our care for you, and the services and/or Items that we provide to you. By law, we are required to m sure that your Protected Health information is kept private.

The following are ways In which we could use or disclose your information. All information is shared thru mail, phone or email.

-For dental treatment

-For appointment and patient recall reminders

-In response to requests arising from lawsuits or other disputes

-To avert a serious threat to health or safety

-In emergency situations

-Correspondence to your other dentists office in regards to insurance and/or payment information

-To run our practice more efficiently and ensure all patients receive quality care

 

If you believe that your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact the office manager. All complaints must be submitted in writing You will not be penalized for filing a complaint.

You have certain rights regarding the information that we maintain about you. These rights include:

-The right to inspect and copy

-The right to amend

-The right to request restrictions

-The right to a paper copy of this notice

-The right to request confidential communications