NEW PATIENT ADULT Patient Details

NEW PATIENT ADULT Contact Information

Spouse  or Additional Contact Information 

NEW PATIENT ADULT Primary Dental Insurance

Secondary Dental Insurance

NEW PATIENT ADULT Medical History

  •  Yes
  •  No

Women ONLY

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Teeth
  •  Mouth
  •  Chin
  •  Clenching/Grinding Teeth
  •  Lip Sucking/Biting
  •  Nail biting
  •  Prolonged Bottle/Pacifier
  •  Mouth Breather
  •  Tongue Thrusting
  •  Thumb/ Finger Sucking
  •  None
  •  Yes
  •  No
  •  Aspirin
  •  Codeine
  •  Tetracycline
  •  Erythromycin
  •  Penicillin
  •  Latex
  •  Any Metals/Plastics
  •  None

Signatures

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this office of any changes in my medical status. 

I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the office. I understand that where appropriate, credit bureau reports may be obtained. 

 

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NEW PATIENT ADULT

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to Patient 

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information Please sign this form to acknowledge receipt of the Notice You may refuse to sign this acknowledgement, if you wish 

I acknowledge that I have received a copy of this office's Notice of Privacy Practices  

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NEW PATIENT ADULT

E-MAIL RELEASE FORM

I,

Want to communicate via e-mail with Minnesota Orthodontics on matters related to my financial / insurance information and my dental treatment I understand that any Confidential Health Information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, or any of its workforce members, liable for loss of any confidentiality associated with information transmitted via e-mail. Standard message and data rates may apply to text messages. 

I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent to me via e-mail. Because this information is not encrypted I understand that it is not secure. I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions. 

  •  DECLINE E-mail Communication
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*By declining any email communication. You will not receive appointment reminders via email. *'There will be no communication with your general dentist via email (which most dentists prefer) *You will not be able to send or receive requests to our office through our secure website. 

HIPAA E-Mail Release Form 

Before sending any non-encrypted e-mail communications (including attachments) containing Protected Health Information to any recipient, ensure that this Form has been signed and is on file Provide a copy to the Patient. Form 12 

NEW PATIENT ADULT

Release of Records/ Share Personal Health Information 

hereby request and give my permission  to Minnesota Orthodontics to provide:

any and all information which he/she may request with respect to the orthodontic care including financial information of 

Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, x-rays, models and copies of all dental and medical records. 

I agree to pay the cost of duplicating any records. A photocopy of this release will be as effective and valid as the original. 

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NEW PATIENT ADULT Media Release Form

AUDIO/PHOTO/VIDEO MEDIA RELEASE FORM

I grant permission to Minnesota Orthodontics and its agents or employees to use photographs and/or video and audio taken of me. These images may be used in advertisements, brochures, newsletters, posters in both printed and/or online media. I understand that my images may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my images or recordings.

I hereby agree to release, defend, and hold harmless Minnesota Orthodontics and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.

Before signing below, you have read this and fully understand the contents, meaning, and impact of this release. As the signer you understand that you are free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and have agreed that your failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

If under age 18, there must be a consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of the below and do hereby give my consent without reservation to the foregoing on behalf of this person.

  •  Decline
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