Z&G Child New Patient Paperwork

PRIVACY, COMMUNICATION & AUTHORIZED ADULTS
Child New Patient Packet • Please complete all sections. You will sign once, on the final page.
NOTICE OF PRIVACY PRACTICES
COMMUNICATION PREFERENCES
I authorize Zammitti & Gidaly Orthodontics to contact me about appointments, treatment, and my account using the method(s) checked below. Standard message and data rates may apply. I may opt out of text messages at any time by replying STOP. I understand that email and text messages may not be encrypted.
Preferred contact methods (check all that apply and fill in)
Phone Number
Format: (000) 000-0000.
Mobile Number
Format: (000) 000-0000.
Email Address
example@example.com
May we leave a detailed voicemail or message?
RELEASE OF INFORMATION TO OTHERS
I authorize Zammitti & Gidaly Orthodontics to discuss my child's care, appointments, and account with the individuals below. (Parents/guardians on the Health History Form do not need to be listed again.)
Name 1

First NameLast Name
Relationship 1
Phone 1
Format: (000) 000-0000.
Name 2

First NameLast Name
Relationship 2
Phone 2
Format: (000) 000-0000.
Name 3

First NameLast Name
Relationship 3
Phone 3
Format: (000) 000-0000.
AUTHORIZED ADULTS TO ACCOMPANY PATIENT
When I am unable to attend, I authorize the adult(s) below (18 or older) to bring my child to routine appointments. Photo ID may be requested. A parent or legal guardian must attend the initial consultation and any visit where treatment decisions are made.
Authorized Adult Name 1

First NameLast Name
Authorized Adult Relationship 1
Authorized Adult Phone 1
Format: (000) 000-0000.
Authorized Adult Name 2

First NameLast Name
Authorized Adult Relationship 2
Authorized Adult Phone 2
Format: (000) 000-0000.
Authorized Adult Name 3

First NameLast Name
Authorized Adult Relationship 3
Authorized Adult Phone 3
Format: (000) 000-0000.
These authorizations remain in effect until I revoke them in writing (704-947-9991). Treatment does not depend on signing them. Information shared with others may be re-disclosed and may no longer be protected by federal privacy law.
PHOTO & VIDEO RELEASE
We love celebrating our patients' smiles! By selecting "I give permission," I allow Zammitti & Gidaly Orthodontics to use photos and videos of my child's smile and results on our website, social media, and marketing materials. My child's full name will never be shared without separate permission. This choice is optional and will not affect my child's care.
Photo / Video Release Permission
Acknowledged and signed on the Acknowledgment & Signature page at the end of this packet.
Concord: 10040 Edison Sq. Dr. NW, Concord, NC 28027 • Davidson: 130 Harbour Place Dr., Ste. 100, Davidson, NC 28036 • Harrisburg: 4079 Harris Sq. Dr., Harrisburg, NC 28075
Zammitti & Gidaly Orthodontics • 704-947-9991 • charlottebraces.com • Privacy & Authorized Adults • Page 5 of 7

ORTHODONTIC OFFICE POLICIES
Welcome to our practice! We value a healthy, transparent relationship with your family, built on trust and communication.
Please read each section and initial where indicated.
APPOINTMENTS & SCHEDULING
Parent Initials
- CONSISTENT VISITS KEEP TREATMENT ON TRACK
  – Orthodontic treatment depends on regular adjustment appointments. Please schedule your next visit before leaving the office.
- ARRIVAL TIME
  – Please arrive on time. If you expect to be more than 10 minutes late, please call us; we will do our best to accommodate you, but your appointment may need to be rescheduled.
- CANCELLATIONS & RESCHEDULING
  – Please give at least 24 hours' notice if you need to reschedule.
  – Missed or repeatedly rescheduled appointments can lengthen treatment time.
- APPOINTMENT REMINDERS
  – We send reminders by call, text, and/or email as a courtesy. Reminders are not a guarantee; please keep track of your scheduled visits.
ACCOMPANYING PATIENTS
Parent Initials
- A parent or legal guardian must attend the initial consultation and any appointment where treatment decisions are made or consent is signed.
- For routine visits, the patient may be accompanied by an adult listed on our Authorized Adults form.
- The accompanying adult should remain on site and available during the appointment.
FINANCIAL EXPECTATIONS
Parent Initials
- RESPONSIBLE PARTY
  – The person who signs the Orthodontic Financial Agreement is responsible for the treatment it covers, regardless of insurance coverage or any custody arrangements.
  – The person completing this packet is responsible for any services provided without a signed financial agreement.
- TREATMENT FEES & PAYMENT ARRANGEMENTS
  – Your treatment fee and payment plan are reviewed with you and documented in a separate financial agreement before treatment begins.
- INSURANCE
  – As a courtesy, we will file claims with your primary dental insurance. Benefits quoted are estimates only.
  – We do not bill secondary insurance, but we will provide the documentation needed for the responsible party to submit those claims.
  – Orthodontic benefits often carry a lifetime maximum and are commonly paid over the course of treatment.
  – Please notify us right away of any change in your insurance coverage.
DIAGNOSTIC RECORDS & CARE
Parent Initials
- I consent to the diagnostic records needed to evaluate and treat the patient, including x-rays, photographs, and digital scans or impressions. These records are part of the patient's confidential health record.
- Good results depend on teamwork. We ask that patients follow home-care, appliance, and elastic instructions and keep regular cleanings with their family dentist during treatment.
Acknowledged and signed on the Acknowledgment & Signature page at the end of this packet.

ACKNOWLEDGMENT & SIGNATURE
One signature covers every section of this packet. Please check each box to confirm.
By checking each box and signing below, I, the parent/legal guardian and responsible party for the patient named on the Health History Form, confirm the following:
Acknowledgment Options
PARENT / GUARDIAN SIGNATURE
Parent/Guardian Name (Print)

First NameLast Name
Relationship
Parent/Guardian Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: