CONFIDENTIAL
Medical Dental History Form
For Patients Under Age 18
Date
Patient’s Last Name First Name
Birth Date Sex: (circle) Male Female
Home Address
Cell PhoneHome Phone
DAD’S INFORMATION
Full Name______FatherStepfather Legal Guardian
Address (if different than child)______
Cell Phone______Alternate Phone______Email______
MOM’S INFORMATION
Full Name______Mother Stepmother Legal Guardian
Address (if different than child)______
Cell Phone______Alternate Phone______Email______
DENTIST
DENTIST NAME~dentist~City/State______
Last Exam/Cleaning______
REFERRAL
Who can we thank for referring you to our office?
DENTAL INSURANCE
Primary Policy Holder
Social Security Number/ID # ______
Policy Holders Birthday Employer
Insurance CompanyGroup #
MEDICAL HISTORY – Please check all that apply
AsthmaCancerMedications______
AnemiaHeart Conditions/High Blood PressureAllergies ______
DiabetesHeart MurmurDoes your child need premedication before dental procedures? __
EpilepsySeizuresOther ? ______
Hepatitis or HIV/AIDSTuberculosis
DENTAL HISTORY – Please check all that apply
Do your child maintain 6 month dental Check Ups? Has your child had an orthodontic consultation in the past?Other______
Does your child grind or clench his/her teeth?Has your child had prior orthodontic Treatment?
Does your child suck his/her thumb/fingers?Does your child’s jaw click or lock when opening/closing?
SIGNATURE FOR HEALTH HISTORY
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 this form. I will notify my orthodontist of any changes in my medical or dental health.
Parent/Guardian Signature______Date______
HIPPA RELEASE AND WAIVER
(Guide To Patient Privacy Rules Is In Waiting Room)
I consent to the use or disclosure of my protected dental health information by Meier Orthodontics for the purpose of diagnosing or providing treatment to me, obtaining payment for my dental health care bills or to conduct dental health care operations of Meier Orthodontics. I understand that diagnosis or treatment of me by Scott F. Meier, D.D.S. may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected dental health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Meier Orthodontics is not required to agree to the restrictions that I may request. However, if Meier Orthodontics agrees to a restriction that I request, the restriction is binding on Meier Orthodontics and Scott F. Meier, D.D.S..
I have the right to revoke this consent in writing, at any time, except to the extent that Scott F. Meier, D.D.S., or Meier Orthodontics has taken action in reliance on this consent.
My “protected dental health information” means dental health information, including my demographic information, collected from me and created or received by my orthodontist, another dental health care provider, a health plan, my employer or health care clearinghouse. This protected dental health information relates to my past, present or future physical or dental health or condition and identifies me, or there is a reasonable basis to believe the information may indentify me.
I understand I have a right to review Meier Orthodontics’s Notice of Privacy Practices prior to signing this document. The Meier Orthodontics’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected dental health information that will occur in my treatment, payment of my bills or in the performance of dental health care operations of the Meier Orthodontics. The Notice of Privacy Practices for Meier Orthodontics is also provided in the reception area. This Notice of Privacy Practices also describes my rights and the Meier Orthodontics’s duties with respect to my protected dental health information.
Meier Orthodontics reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
______
Signature of Patient or Personal RepresentativeDate
1