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  • English (US)
  • John C. Griffiths, D.D.S., M.D.S.

    Douglas K. Simister, D.D.S., P.C.

    Mark A. Whiting, D.M.D., M.S.

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  •  Patient Information


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  • If Patient is under 18 years of age please list First Parent/ Guardian's Information

    (type SELF in required fields if you are over 18 years old) 

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  • Second Parent/ Guardian's Confidential Information

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  • Insurance Information

    (If you do not have insurance type None in required fields)

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  • Please provide us with a copy of your current insurance card (Front & Back)

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  • Please provide us with a copy of your current insurance card (Front & Back)

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  • Emergency Information

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  • Medical History

  • DENTAL HISTORY

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  • Acknowledgment of Receipt of Statement of Privacy Practices

    I acknowledge that I have recieved a copy of the Statement of Privacy Practices for the offices of Griffiths and Simister Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment or services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

    Griffiths and Simister Orthodontics reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

  • ADDITIONAL DISCLOSURE AUTHORIZATION

    In addition to the allowable disclosures described in the Statemet of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

     

     

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