Braces by Berry - Patient Information Form (Child)

Patient Information Form (Child)
Patient's Name*

First NameLast Name
Prefers to be called
Nickname, Preferred Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender

MaleFemale
Patient's Home Address*

Street Address

Apartment or Suite

CityState

Zip Code
Patient's Phone Number*
Please enter a valid phone number.
Patient Phone Type*

HomeCellWork

Billing Information / Responsible Party
Responsible Party*

First NameLast Name
Has the responsible party been entered as a Parent / Legal Guardian previously?*

YesNo
Relationship to Patient*
Responsible Party Address*

Street Address

Apt / Suite

CityState

Zip Code
Responsible Party's Spouse's Name (if applicable)
Responsible Party's Phone Number*
Please enter a valid phone number.
Responsible Party's Phone Type*

HomeWorkCell

Dental Insurance Information
Do you have dental insurance?*

YesNo
Do you have orthodontic coverage?*

YesNo
Member Name*

First NameLast Name
Relationship to Patient*
Member Date of Birth*

MonthDayYear
Date
Member Social Security Number*
Member Employer*
Insurance Company*
Insurance Company Phone*
Please enter a valid phone number.
Member ID*
Group Number*

Wrapping Up
How did you hear about Braces by Berry?*
Whom may we thank for the referral?*
Doctor / Family / Friend Name
Does the patient have other family members seen by us?*

YesNo
Please list other family members and their relation.
What school does your child attend?*
Does your child play any musical instruments?*

YesNo
Does your child participate in sports?*

YesNo
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my/my child's medical status. I authorize the dental staff to perform any necessary dental services that my child may need during diagnosis and treatment with my informed consent.
Parent / Legal Guardian Signature

Clear
Signature Date*

MonthDayYear
Date

Patient Consent to Use and Disclosure Information for Treatment, Payment, and Health Care Operations
Adult completing this form

First NameLast Name
Patient's Name

First NameLast Name
I, as the parent or legal guardian for the above stated child understand that as part of my heath care, Dr. L. Ruth Berry, D.M.D., P.A. originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis from planning my care and treatment.
- A means of communication among the dental professionals who contribute to my care, such as referrals.
- A source of information for applying my disagnoses and treatment information to my bill.
- A means which a third-party can verify that services billed were actually provided.
- A tool or routine operations, such as assessing quality reviewing the competence of staff.
I have been provided with a Notice of Patient Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to view Notice prior to signing this consent
- The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations, treatment, payment.
I wish to have the following restrictions to the use of disclosure of my health information.
Please tell us with whom we may discuss your / patient's treatment, payment or healthcare operations:
Example: relatives, friends, caregivers, and dentists.
I further understand that Dr. L. Ruth Berry, D.M.D., P.A. reserves the right to change her notice and practices, in accordance with the Section 164.520 of the Code of Federal Regulation. Should Dr. L. Ruth Berry, D.M.D., P.A. change her notice, I may request a copy of any revised notice in person (or by U.S. mail, to be send to the address I have provided).
Appointment Reminders:
May we leave an appointment reminder message at your home using doctor's / practice name?*

YesNo
May we leave an appointment reminder message at your work using doctor's / practice name?*

YesNo
I understand that as part of treatment, payments, or healthcare operation, it may become necessary to disclose health information to another entity (i.e., referrals to other healthcare providers). I consent to such disclosure for these use as permitted by law.
I fully understand and accept or decline the terms of this consent.*

AcceptDecline
Parent / Legal Guardian's Name

First NameLast Name
Parent / Legal Guardian's Signature

Clear
Signature Date*

MonthDayYear
Date

Photographic Waiver and Consent
So that we may provide you with the best possible state-of-the-art orthodontic services available, we feel it is necessary to take photographs. We would appreciate you taking the time to read and sign this consent form.

I hereby give permission to L. Ruth Berry, D.M.D., P.A., Dr. L. Ruth Berry, or any staff she may designate, to take photographs for diagnostic purposes and to enhance the dental records. I agree that these photographs will remain the property of Dr. L. Ruth Berry.
Patient's Name

First NameLast Name
Patient's Signature or Parent / Legal Guardian's Signature (if under 18)

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Information Form (Child)

Patient's Family Information

Billing Information / Responsible Party

Dental Insurance Information

Dental History (Child Patient)

Medical History (Child Patient)

Wrapping Up

Patient Consent to Use and Disclosure Information for Treatment, Payment, and Health Care Operations

Photographic Waiver and Consent