(It is important to have had a dental examination & cleaning within 6 months prior to starting orthodontic treatment)

Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the end results of your orthodontic treatment. Thank you in advance for answering the following questions. All information will be kept confidential. 

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the office of any changes in medical status. 

We take great pride in providing the BEST care available!!

Consent for use and Disclosure of Your Protected Health Information

SECTION A: PATIENT GIVING CONSENT

SECTION B: 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 treatment, payment activities, and healthcare operations. 

Notice of Privacy Practices: You have the right to read our Notice of Privacy before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, healthcare operations, and of the use and disclosures we may make your protected health information, and of other important matters about your protected health information. A copy of our Notice 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. Those changes may apply to any of your protected health information that we maintain. 

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

Insoft & Hurst Orthodontics 
6700 Crosswinds Dr N, Suite 300B, St. Petersburg, FL 33710
Phone: (727) 384-4511 Fax: (727) 342-0610
yoursmile@braceinfo.com

Right to Revoke: You will 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, and that we may decline to treat you or to continue treating you if you revoke this Consent. 

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. 

Include completed form in Patient's Chart

Patient Photo Release Form 

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. 

I understand your Notice of Privacy Practice, which contains a more complete description of the uses and disclosures of my health information. 

This release is strictly designed to give permission to Insoft & Hurst Orthodontics, to use my digital patient photos for their website, Social Media, and in office presentation for both educational and promotional purposes. Insoft & Hurst Orthodontics will have permission to use these photos in the manner discussed with me, unless I request the office no longer use them. I understand that by allowing Insoft & Hurst to use my photos, they are able to share "before and after" images of my teeth to educate and explain procedures and possible results of treatment. Insoft & Hurst Orthodontics will not disclose names or full-face photos. I understand that I have the option to decline this request and am not obligated in any way to provide permission to use these photos.