Winnie Orthodontics New Patient Form for Minors Under 18

Today's date

MonthDayYear
NEW PATIENT FORM - MINOR (UNDER 18)
Name*

First NameLast Name
Nickname
Birth date*

MonthDayYear
Date
Gender*

MaleFemale
Address

Street Address

Street Address Line 2

CityState

Zip Code
Grade
Hobbies/Sports
GENERAL INFORMATION
Who may we thank for recommending our office to you?*
General Dentist*
Last Visit Date

MonthDayYear
Date
Dentist Phone Number
Parent's Marital Status

SinglePartneredWidowedDivorcedSeparated
Who is main person responsible for the account?*

FatherMotherGuardianOther
CHILD'S PRIMARY PARENT/GUARDIAN INFORMATION
Name*

First NameLast Name
Birth date *

MonthDayYear
Date
Address (if different from patient)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
Employer
Occupation
CHILD'S SECONDARY PARENT/GUARDIAN INFORMATION
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Address (if different from patient)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer
Occupation
INSURANCE INFORMATION

If you have insurance for your child, please provide us with the following information:
Insurance Company Name (Enter "none" if no insurance)*
Insurance Phone #
Group #
Subscriber ID OR Social Security Number (enter 0 if no insurance)*
Please Upload Driver License or Picture ID of Responsible Party*

Cancelof
Please Upload the FRONT of your insurance card

Cancelof
Please Upload the BACK of your insurance card

Cancelof
MEDICAL HISTORY
Child's Pediatrician/Family Physician
Phone Number of Physician
Please enter a valid phone number.
Your child's current physical health is:*

GoodFairPoor
Is your child currently under the care of a physician?*

YesNo
If Yes, please explain:
Does your child smoke or use tobacco of any kind?*

YesNo
Has your child had any metal rods, pins or implants?*

YesNo
Is your child taking any prescription/over-the-counter medications?*

YesNo
If Yes, please list each one:

Has your child ever had any of the following diseases or medical problems:*

	Yes	No
Abnormal bleeding/Hemophilia
AIDS
Anemia
Arthritis
Artificial bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for any reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease

List any other medical condition(s) that your child has ever had:

Is your child ALLERGIC to any of the following?*

	Yes	No
Aspirin
Erythromycin
Penicillin
Codeine
Jewelry/Metals
Tetracycline
Dental Anesthetics
Latex
Other (please specify below)

Other Allergies Not Listed Above
DENTAL HISTORY
What are the main orthodontic concerns you would like to accomplish for your child?*
Has your child ever been evaluated for orthodontic treatment*

YesNo
Has your child ever experienced pain or discomfort in their jaw joint (TMJ/TMD)? If Yes, please describe history and duration of problem
Please list any injury your child has ever had to the oral and facial areas:
Does your child require antibiotics before dental procedures?*

YesNo
How many times does your child brush daily?*
How many times does your child floss daily?*
What orthodontic treatment are you interested in for your child?*

Traditional metal bracesCeramic clear bracesClear AlignersLingual BracesOther
What is most important to your child's orthodontic care? Please select all that apply.*

EstheticsTechnologyPriceComfortSpeedConvenience
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I hereby confirm that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that 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/orthodontic services my child may need.

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance company does not cover. I authorize Winnie Orthodontics to release all information necessary to secure the payment of benefits. I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Responsible Party's Signature*

Clear

NOTICE OF PRIVACY
The Health Insurance Portability and Accountability Act of 1996 (HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

Treatment means provided, coordinating, or managing health care and related services by one or more health care providers. An example of this would include teeth cleaning services

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorizations in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

The right to inspect and copy your protected health information.

The right to amend your protected health information.

The right to receive an accounting of disclosures of protected health information.

The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of legal duties and privacy practices with respect to protected health information.

Please note that we are not obligated to provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

This notice is effective as of January 1, 2014 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office or with the Department of Health & Human Services Office of Civil Rights about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information.

For more information about HIPAA or to file a complaint:

The US Department of Health & Human Services
Office of Civil Rights
200 Independence Ave SW
Washington DC 20201
(202) 619-0257
Toll Free: 877-696-6775
Patient Name or Guardian if Patient under 18*

First NameLast Name
Signature of Patient or Guardian if Patient is under 18*

Clear
Date*

MonthDayYear
Date
Should be Empty:

NEW PATIENT FORM - MINOR (UNDER 18)

GENERAL INFORMATION

CHILD'S PRIMARY PARENT/GUARDIAN INFORMATION

CHILD'S SECONDARY PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

NOTICE OF PRIVACY