• ORTHODONTIC CHILD REGISTRATION

  • Date*
     / /
  • Format: (000) 000-0000.
  • Patient lives with:*
  • Sex:*
  • Patient Adopted?*
  • Parents Are:*
  • Patient Looks Like:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have Dental Insurance?*
  • Format: (000) 000-0000.
  • General Health*
  • Is Patient Taking Medication?*
  • Have you Ever Been Treated For?
  • Have Tonsils/Adenoids been removed?*

  • Has Patient reached puberty? - 

  • Girls - menstruation started?
  • Boys - Voice changed?

  • Does the patient have a history of: 

     

  • Finger or Thumb Sucking:*
  • Suck Tongue or other objects:*
  • Suck lower lip between upper/lower teeth:*
  • Nailbiting:*
  • Did the patients teeth erupt:
  • Have there been any injuries to the teeth or jaw?*
  • Have any teeth been lost early due to accidents?*
  • Have any teeth been removed with the intent of making space for other teeth to erupt?
  • Have any space maintainers been worn?*
  • Have "Braces" (Orthodontic Appliance) ever been worn?*
  • Has anyone in the family been treated or examined by an Orthodontist before?*
  • Previous Dental Experiences:

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

  • Were X-rays taken?
  • Is all dental work complete?
  • Is Patient a mouth breather?*
  • Any jaw issues?
  • Does the patient play any musical instruments with the mouth?
  • Google*
  • Invisalign Website*
  • Doctor/Dentist*
  • Referred by a current patient?*

  • Patient referrals are the best compliment to our practice! Thank you in Advance for your trust in us!! 

     

  • (A parent or legally responsible adult must accompany patient under 18 years of age at initial visit) 

     

    (We take great pride in providing the BEST care available) 

     

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  • Consent for use and Disclosure of Your Protected Health Information

  • SECTION A: PATIENT GIVING CONSENT 

  • Date*
     - -

  • 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 Practices 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 of 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 our 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) 341-0610
    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 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 to continue treating you if you revoke this Consent.

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

     

  • 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

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  • 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 Practices, 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 Orthodontics 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.

  • RESPONSIBLE PARTY'S Signature Date*
     - -
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  • Should be Empty: