Child Registration

Patient Name*

First NameLast Name
Gender*

MaleFemale
Identifies As
Birth Date*

YearMonthDay
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Phone Number

Area CodePhone Number
Patient's Phone Type
Patient's E-mail
School
Grade
Extracurricular Activities
Siblings (Names and Ages)
Parent's Marital Status

SingleMarriedDivorcedOther
______________________________________
First Parent
Name*
Social Security #
Required for insurance verification
E-mail*
Birth Date

MonthDayYear
Address (If different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone*

Area CodePhone Number
Primary Phone Type
Secondary Phone

Area CodePhone Number
Secondary Phone Type
Employer's Name
Occupation
______________________________________
Second Parent
Name
Social Security #
Required for insurance verification
E-mail
Birth Date

MonthDayYear
Address (If different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone

Area CodePhone Number
Primary Phone Type
Secondary Phone

Area CodePhone Number
Secondary Phone Type
Employer's Name
Occupation
______________________________________
Emergency Contact Name (other than parent)
Relation to child
Emergency Contact Phone Number

Area CodePhone Number

Dental Insurance
Do You Have Dental Insurance?*
Primary Insurance Company
Phone Number
Group Number
Subscriber ID
Policy Holder's Name
Policy Holder's Birth Date

MonthDayYear
Relation
Employer
Work Phone #

Area CodePhone Number
______________________________________
Secondary Insurance Company
Phone Number
Group Number
Subscriber ID
Policy Holder's Name
Policy Holder's Birth Date

MonthDayYear
Relation
Employer
Work Phone #

Area CodePhone Number

Records Consent
I consent to allow the orthodontist and staff members at Kottemann Orthodontics to take orthodontic "Records" if indicated. This includes but is not limited to a Panoramic Radiograph, Cephalometric Radiograph, Digital Scan and Photos.
Signature*

Clear
Date

MonthDayYear

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES & CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION PATIENT
Patient Name*

First NameLast Name
TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out our treatment, payment activities and healthcare operations. Notice of Privacy Practice: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and other important matters about your protected health information. A copy of our Notice of Privacy Practices accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. These changes may apply to any of your protected health information that we maintain.

You may obtain another copy of our Notice of Privacy Practices, including revisions, at any time by contacting:

Privacy Officer : Ashley
Telephone: 763-420-6834
Fax: 763-4205634
13998 Maple Knoll Way, Suite 102
Maple Grove, MN 55369

Consent Does Not Expire after One Year. By signing this Consent form, I am explicitly giving informed consent for the release of health records and health information for the purposes listed herein and that this Consent does not expire after one year for 1) the release of health records to a provider who is being advised or consulted with in connection with the releasing provider’s current treatment of myself; or, 2) the release of health records to an accident and health insurer, health service plan corporation, health maintenance organization, or third-party administrator for purpose of payment of claims, fraud investigation, or quality of care review and studies.

Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Privacy Officer listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent. You may obtain a revocation of consent form upon request.

Signature: I have received a copy of this practice’s Notice of Privacy Practices and have had the full opportunity to read and consider the contents of this Consent form. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature*

Clear
If over 18, please indicate names of persons we are able to speak with regarding your treatment
Personal Representative Name*
NOTE: A parent is considered a Personal Representative for a minor under the HIPAA Privacy Regulations.
Relationship to Patient*
Date

MonthDayYear

v I 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 of confidence and it is my responsibility to inform the office of any changes in my medical status.

v I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
Signature*

Clear
Date

MonthDayYear
Should be Empty:

	Yes	No
Has your child's adenoids or tonsils been removed?
Has your child ever experienced jaw joint pain?
Does your child have any missing or extra permanent teeth?
Does your child's gums bleed?
Does your child smoke?
Does your child have speech problems?
Have you ever had an injury to the mouth or jaw?
Do you like your smile?

	Yes	No
Psychological Disorders (Including ADHD)
Kidney or Liver Disease
Glaucoma
Hypertension
Airway/Breathing Disorders
Sleep Disorder

	Yes	No
Frequent Loud Snoring
Disruption of Breathing During Sleep
Frequent Mouth Breathing
Frequent Daytime Sleepiness

Dental Insurance

Dental History

Health History

Records Consent

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES & CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION PATIENT