NEW PATIENT CHILD Patient Information

NEW PATIENT CHILD Parent Information

Parent #1

Parent #2

NEW PATIENT CHILD Primary Dental Insurance

  •  Yes
  •  No

NEW PATIENT CHILD Secondary Dental Insurance

NEW PATIENT CHILD General Information

NEW PATIENT CHILD Medical History

  •  Yes
  •  No

FOR BOY

  •  Yes
  •  No

FOR GIRL

  •  Yes
  •  No
  •  N/A
  •  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 confidence and it is my responsibility to inform this office of any changes in my child's 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 CHILD Acknowledgement of Receipt of Notice of Privacy Practices

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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(Your IP Address :IP:3.239.33.139 )

NEW PATIENT CHILD E-MAIL RELEASE FORM

I, 

Want to communicate via e-mail with Minnesota Orthodontics on matters related to my financial/insurance information ad 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 practices to encrypt any Confidential Health information I request to be sent to me via e-mail. Because of 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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(Your IP Address :IP:3.239.33.139 )

- 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 able to send or receive requests to our office through our service 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 CHILD 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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(Your IP Address :IP:3.239.33.139 )

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