Please list any other physicians your child seesPhysician Name 1 City, State 1 Reason 1Physician Name 2 City, State 2 Reason 2
Please list any medication, nutritional supplement, herbal medication or non-prescription medicines, including fluoride supplements that your child takes.Medication 1 taken for Reason 1 taken for taken for taken forMedication 5 taken forReason 5Medication 6 taken forReason 6Medication 7 taken forReason 7Medication 8 taken forReason 8
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of the form. I will notify my Child's 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.