ADULT PATIENT INFORMATION
EMERGENCY CONTACT INFORMATION
Retention of Documents Relating to Patient Care. By signing this, you understand and agree that is it our policy to scan and store original documents in electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed in electronic form, has the same force and effect as the original document.
(Aclasta, Actonel, Actonel+Ca, Aredia, Atelvia, Binosta, Bonefos, Boniva, Didronel, Foasmax, Fosamax+D, Reclast, Skelid, or Zometa)
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment. It is my responsibility to inform this office of any changes in my personal information or health status. I will not hold mBrace Orthodontics or the staff responsible for any errors or omissions that I have made in the completion of this form
Adult Sleep Assessment and Epworth Scale
Please list any medical problems within the last 5 years (hypertension, diabetes, surgery, etc.)
Circle the appropriate response:
Do you frequently awaken with (Check all that apply):
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dr. Shireen Irani and mBrace Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility and available upon request
Dr. Shireen Irani and mBrace Orthodontics reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices upon request.
ADDITIONAL DISCLOSURE AUTHORITY
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.