• Welcome to Southwest Pediatric Dentistry & Orthodontics!

    Please take a few minutes to fill out this form as completely as you can. We look forward to being a part of your smile journey!
  • Patient Information

    Adult Orthodontic Registration
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  • Insurance Information

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  • Dental & Orthodontic History

  • Medical History

  • For Females Only

  • HIPAA ACKNOWLEDGMENT

  • ACKNOWLEDGMENT OF PRIVACY POLICY

    As required by the HIPAA Privacy Regulations, all patients (or patient’s personal representative) who receive health care services on or after April 14, 2003 must:

    • Receive and review the attached “Notice of Privacy Practices”, and
    • Review and sign the “Acknowledgment Form” for our records.

    I have been presented with a copy of this provider’s Notice of Privacy Policies below, detailing how my information may be used and disclosed as permitted under federal and state law. 

    Further, I permit a copy of this authorization to be used in place of the original. Please note that the attached Notice of Privacy Policies is not a consent form that must be read in full by the patient and signed before treatment can be provided; rather, the Notice provides each patient with a summary description of:

    • How our office will use and disclose their medical information for legitimate business purposes,and
    • How each patient can exercise their rights regarding this medical information. If you have any questions about this notice, please call our office at (303) 978-1104 and ask for our HIPAA compliance administrator.
  • CONSENT FOR DISCLOSURES TO FRIENDS AND /OR FAMILY MEMBER

    I authorize Southwest Pediatric Dentistry & Orthodontics, PC to share my Protected Health Information to be disclosed for purposes of communicating results, findings, treatment decisions and financial issues to the family members and others listed below. This will serve as my electronic signature for the Consent for Disclosure Form (If a power of attorney, please provide a copy of the POA).

  • FINANCIAL/INSURANCE AND OFFICE POLICIES

  • Payment Policy

    Full payment is due at time of service. We accept cash, personal checks, Visa, MasterCard, American Express, Discover, and have payment plans available through CareCredit. If you have insurance, we will collect applicable copays/deductibles.

    Returned Checks

    Policy Returned checks are subject to a $35 return check fee.

    Dental Benefits

    You are responsible for understanding your dental benefits and have ultimate financial responsibility for your account, regardless of whether your dental insurance benefit covers part of your treatment. We are happy to provide you with an estimate of what we believe your dental benefits will cover based on information provided to us by your benefit provider. Dental services that require laboratory fabrication (e.g. athletic/night guards, pontics, retainers) require full payment at time of impression. Retail Products, Sonicare toothbrushes, Clinpro Toothpaste & whitening products are non-returnable and must be paid in full at time of purchase.

    Past Due Accounts

    Accounts more than 90 days past due may be transferred to a collection agency. Patients shall be responsible for all costs incurred for the collection of past due balances. This includes collection agency fees, attorney fees, and any other costs involved in litigation.

  •  Appointment policy

    We realize that there are often circumstances in which you cannot control and we will try to work with you, so please let us know the reason for cancellation.

    • 24-hour Cancellation/No Show policy – We request 24-hour cancellation notice in order to give other patients the opportunity to receive treatment. Please give us as much notice as possible when canceling an appointment.
      • You will be charged $75 for a cancelled scheduled appointment when notice given is less than 24 hours before appointment time or for failing to attend your scheduled appointment without 24-hour cancellation notification.
      • Exceptions will be made for illness and inclement weather.
    • Late Arrival policy – In the event you arrive late for your appointment, your treatment will end at its scheduled time in order not to keep the next person waiting. Remaining services will be scheduled at another time.
  • Consent for electronic communication

    To serve you better, Southwest Pediatric Dentistry and Orthodontics, PC (SWPDO) sends automated SMS Text Message and email appointment reminders. These reminders do not contain Protected Health Information (PHI). At your request, we can also communicate with you for scheduling appointments, providing PHI to you or an authorized recipient, or for other reasons that may contain your PHI. By selecting below, I authorize SWPDO to contact me by the means selected to the contact information.

    • By authorizing, I acknowledge that I have read and understand the following: Message/data rates may apply to messages sent to my cell phone.
    • I may opt-out of receiving these communications at any time by calling SWPDO at (303) 978-1104 or replying to the text or email as indicated in the message.
    • As a general practice SWPDO does not send PHI by email, unless requested by the patient or authorized person to be sent by email. If I request anything containing my PHI to be sent electronically, I understand that PHI could possibly be read by unintended parties such as but not limited to the following: people that have access to my devices that receive my email, my email provider, my company (if using company email), stored on servers that are not HIPAA security compliant, etc.
  • I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge and will be held in the strictest of confidence. I understand that this information will be used by the treating provider to help determine appropriate and helpful dental or orthodontic treatment. I also understand that if there is any change to my, or the above-named patient's dental or medical status, it is my responsibility to inform the doctor. I authorize the dental staff to perform any necessary dental services that the patient may need during diagnosis and treatment with my informed consent. The parent and or guardian who accompanies the patient is responsible for payment at time of service unless prior arrangements have been provided. I understand that I am responsible for any amount not covered by insurance; including cost of collections, attorney, and court fees. 

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