Information Release Form

Patient Name:

Date of Birth:

Date

Responsible Party Name (If patient under age 18):

Please Call My:

WorkHomeCell

If Unable to reach me:

You may leave a detailed message.Please leave a message asking me to return your callIf unable to reach me:

What should we do if we are unable to reach you?

The best time to reach me is

Please send me a text message reminder for my scheduled appointments.

(Day)

Between (Time)

Cell phone number:

Do NOT send me text message reminders for my scheduled appointments.

Cell phone number:

Signed:

Date:

Date

Relationship to patient:

Witness:

Date

This Release of information will remain in effect until terminated by me in writing.

I hereby authorize Servello Orthodontics the use and disclosure of my protected health information as described below:

My protected health information, including individually identifiable information, such as names dates, photographs, X-rays and study models may be used or disclosed for the purpose of lectures, presentations, publications, research and or Practice Marketing without disclosing or identifying individual private information.

My protected health information such as phone/fax numbers, email addresses, home addresses, social security numbers and demographic area will not be used or disclosed for any of the above purposes but only to other health care providers (general dentist, oral surgeon, etc; Third party payers or spouses (insurance companies, etc) in order to obtain payment of your account; Internally to all staff members who have a role in the treatment; to your family who are involved in your treatment and or to other patients and third parties who may overhear or see incidental disclosures about treatment. This includes all past, present and future healthcare information.

Any other uses of disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke at any time.

I understand that the information used or disclosed under this authorization form may be subject to redisclosure by the person(s) or facility(ies) receiving it and would then no longer be protected by federal regulations. I have the right to refuse to sign this authorization form. If signed, I have the right to revoke this authorization form, in writing at any time. I understand that any action already taken in reliance on this authorization cannot be reversed and my revocation will not affect those actions.

Print patient name

Date

Print patient name Date

Signature of Patient (Parent if minor child)

List any person(s) you authorize disclosure of information:

Spouse

Grandparent

Other

Patient's Name:

Age:

Birthdate:

Date

Name you like to be called:

School:

Grade:

Phone Number

Area CodePhone Number

Address

Street Address Line 2

CityState

Postal / Zip Code

Hobbies/Sports/Musical Instrument:

Who may we thank for referring you to our office?

Name:

Marital Status:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address:

example@example.com

Home Phone:

Cell Phone:

Parent Date of Birth:

Date

Employer:

Occupation:

Insured's Name:

Insured's ID or SS#:

Insured's Date of Birth:

Date

Insurance Co:

Insurance Co. Address

Group #:

Phone:

Insured's Employer:

Do you have dual coverage?

YesNo

Insured's Name:

Insured's ID or SS#:

Insurance Co:

Insurance Co. Address:

Group #:

Phone:

Insured's Employer:

Physician's Name:

Phone:

Dentists Name:

Are you currently under any medical treatment?

YesNo

Do you have pain, clicking, and/or popping noises in the jaw?

YesNo

Are you aware of either clenching or grinding of teeth?

YesNo

Do you have frequent headaches?

YesNo

Do you have ear problems? (Aches, Ringing, Dizziness, Fullness)

YesNo

Do you have difficulty breathing through the nose?

YesNo

Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?

YesNo

Do you have speech problems, or are you in therapy?

YesNo

Have you had your tonsils and or adenoids removed?

YesNo

Has there been any history of: Joint Swelling, Asthma, TB, AIDS, Kidney, Liver Condition, Epilepsy, rheumatic fever, Other Major illnesses?

YesNo

Do you bleed easy?

YesNo

Is there a tendency to faint or become dizzy?

YesNo

Do you have allergies?

YesNo

Are you currently taking any medication?

YesNo

Do you have a heart Condition?

YesNo

Do you pre-medicate?

YesNo

Do you have sleep apnea?

YesNo

Do you smoke or chew tobacco?

YesNo

Have there been any injuries to the teeth?

YesNo

Have you had any permanent teeth extracted?

YesNo

Have we treated any other family members?

YesNo

If so who?

Signature:

Date:

Date

HIPAA

Health History Form

RESPONSIBLE PARTY

INSURANCE INFORMATION

MEDICAL/DENTAL HISTORY