The following two fields are for the information of the parent(s)/legal guardian(s) of the minor patient. If additional spaces are needed, please ask our front office staff during your appointment to update your patient file.
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 confidence and it is my responsibility to inform the office of any changes in my/my child's medical status. I authorize the dental staff to perform any necessary dental services that my child may need during diagnosis and treatment with my informed consent.
I, as the parent or legal guardian for the above stated child understand that as part of my heath care, Dr. L. Ruth Berry, D.M.D., P.A. originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
I have been provided with a Notice of Patient Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
Please tell us with whom we may discuss your / patient's treatment, payment or healthcare operations:
I further understand that Dr. L. Ruth Berry, D.M.D., P.A. reserves the right to change her notice and practices, in accordance with the Section 164.520 of the Code of Federal Regulation. Should Dr. L. Ruth Berry, D.M.D., P.A. change her notice, I may request a copy of any revised notice in person (or by U.S. mail, to be send to the address I have provided).
I understand that as part of treatment, payments, or healthcare operation, it may become necessary to disclose health information to another entity (i.e., referrals to other healthcare providers). I consent to such disclosure for these use as permitted by law.
So that we may provide you with the best possible state-of-the-art orthodontic services available, we feel it is necessary to take photographs. We would appreciate you taking the time to read and sign this consent form.
I hereby give permission to L. Ruth Berry, D.M.D., P.A., Dr. L. Ruth Berry, or any staff she may designate, to take photographs for diagnostic purposes and to enhance the dental records. I agree that these photographs will remain the property of Dr. L. Ruth Berry.