Health History Form

Who may we thank for referring you to our office? *

I, first name* last name* have received a copy of this office’s Notice of Privacy Practices.

I,patient name* consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Peterson Family Orthodontics (hereafter PFO) for any lawful use PFO deems appropriate, including for treatment, advertising his/her/its services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by PFO during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational purposes.    

I understand any image or likeness of me may be altered prior to use if deemed appropriate by PFO. I understand and agree that I have no right to be consumed about or approve of any such alterations before my image is used.              

I understand PFO will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that PFO cannot guarantee my complete privacy in the event my image or likeness is used by third parties.      

I understand and agree that PFO may use information regarding my health conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness. 

I, parent/guardian*have read the foregoing in its entirety and understand its terms.