CHILD MEDICAL HISTORY FORM

We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational.
We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

1. TELL US ABOUT YOUR CHILD:

Last First MI

2. WHO IS ACCOMPANYING THE CHILD TODAY?


3. PARENT'S INFORMATION


4. PERSON RESPONSIBLE FOR ACCOUNT


5. PRIMARY DENTAL INSURANCE


6. DOES/DID THE CHILD HAVE ANY OF THE FOLLOWING?


7. WHAT WOULD YOU LIKE ORTHODONTICS TO ACCOMPLISH?




8. HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS:

Patient Consent for use and Disclosure of Protected Health Information

With my consent, Sierra Orthodontics, may use and disclose my/ my child's protected health information to carry out treatment, payment and healthcare operations.
Please refer to Sierra Orthodontics Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent.
Sierra Orthodontics reserves the right to revise its Notice of Privacy Practice at any time.

With my consent, the office may call my home or other designated locations and leave a message on voice mail or to the person who answers in reference to any items that assist treatment, such as appointment reminders, insurance items, financial questions and any call pertaining to my clinical care including laboratory results.

With my consent, the office may mail to my home or other designated location any items that assist the practice, such as appointment reminder cards and patient statements.

For minor children

With my consent, the office may share treatment care and results with the person that accompanies my child to the orthodontic appointment.

In the case of dual guardianship, both guardians may be contacted about the patient's appointments, treatment progress, and financial information. However, the office will not share either guardian's phone numbers, social security numbers or addresses with the other guardian. Only the patient's information will be shared.

By signing this form, I am consenting to Sierra Orthodontics use and disclosure of my/ my child's personal Health Information needed to carry out treatment.

Consent for Electronic Communication

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by, unauthorized third parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount of protected health information in any communication. Our first email to you will verify the email address you provide.






I understand that the information that I have given is correct to the best of my knowledge, that is will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.









If this office accepts insurance, I understand that I am responsible for payment of services renderedand also responsible for paying any co-payment and deductibles that my insurance does not cover. I herby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.