Chipped or injured primary or permanent teeth?
Please list any other physicians you seePhysician Name 1 City, State 1 Reason 1 Physician Name 2 City, State 2Reason 2
Please list any medication, nutritional supplement, herbal medication or non-prescription medicines, including fluoride supplements that you take.Medication 1 taken for Reason 1Medication 2 taken for Reason 2 Medication 3 taken for Reason 3 Medication 4 taken for Reason 4 Medication 5 taken for Reason 5Medication 6 taken for Reason 6Medication 7 taken for Reason 7Medication 8 taken for Reason 8
I have read the above questions and understand them. I will not hold my orthodontist or any member of their staff responsible for any errors or omissions that i have made in the completion of the form. I will notify my orthodotnist of any changes in my medical or dental health.
I understand that HIPAA permits the disclosure of patient information to coordinate payment (for billing and collections, eligibility determinations, and insurance reimbursement) as well as for treatment purposes (referring patients to other health care providers or consulting and coordinating care with other health care providers). I authorize the release of any information regarding my orthodontic treatment to my dental and or medical insurance company as well as other health care providers for treatment purposes. To find more information about HIPAA and the permitted disclosures to covered entities please visit https://www.hhs.gov/hipaa/for-professionals/covered-entities/fast-facts/index.html.