Child Health History Form

Patient Information

Patient’s full name

Preferred to be called

Patient’s Address

Prefers to be called

Cell Phone

Patient’s Birthday

Age

Gender

Male Female

Patient’s Dentist

Favorite Hobbies

Whom may we thank for referring you?

School

Names/ages of siblings:

Other family members seen by us

Responsible Party Information

Name

SSN

Married Single Divorce

Home Address

No. of years at address:

Cell Phone No.

Email address

Your relationship to patient

Your birthday

Employer

Occupation

Work Phone No.

Spouse’s Name

Spouse's Birthday

Spouse's Cell phone

Email address

Spouse's Employer

Occupation

Primary Dental Insurance Information

Insured’s Name

Insured’s SSN

Insured’s Employer

Insured’s Birthday

Insurance Company Name

Phone No.

Group Number (Plan No.)

ID Number

Relationship to patient

ID Number

Group Number

Relationship to patient

Health History

Medical History

Please explain all checked responses (from previous medical conditions)

List any allergies

List any medications

Dental History

please check if patient has, or has had ...

Any injuries to face, mouth, or teeth?

Any clenching/grinding of teeth?

day

night

both

Thumb, finger, or lip sucking habit?

continuing

discontinued

Frequent headaches?

Mouth breathing when asleep, awake?

Any pain, popping, or locking on opening/closing jaw movement?

Any known missing permanent teeth?

Any muscle tenderness or stiffness in jaw or neck area?

Any known extra permanent teeth?

Any ringing in ear or dizziness?

Any teeth removed by extraction?

Any previous treatment for TMJ problems?

When?

Is there a tongue thrust problem?

Please explain all checked responses (dental history)

Chief Concerns

Add new row

Orthodontic History

Has patient ever been:

evaluated

treated

by any previous orthodontist?

Orthodontist

Last seen

Address

Treatment Started

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature

Date

New Patient Information

Authorization for Release of Patient Information and Use of Records ("Authorization")

I authorize the release of information in the patient's record regarding the patient's treatment, and/or financial obligations related to the patient's treatment, to the parties listed below. I understand that once personal health and/or financial information is disclosed as per this Authorization, the Practice has no responsibility for any further release by the individual receiving the patient's information.

I understand that I may refuse to sign this Authorization and that my refusal to sign this Authorization will neither affect nor limit the patient's ability to obtain treatment or affect any payment, enrollment, or eligibility for benefits.

I understand that I may revoke this Authorization by sending written notification to the Practice's Privacy Officer at the address set forth below; provided, however, that my notice to revoke this Authorization will not apply to actions taken in reliance on this Authorization prior to the date my written notice is received by the Practice's Privacy Officer.

Scott Law Ortho Corp
Attn: Privacy Officer
5400 LBJ Fwy, Suite 800 (Tower 1)
Dallas, TX 75240

This Authorization shall expire upon the earlier of: (i) the termination of the patient's treatment with the Practice; or (ii) my express written revocation of this Authorization with regard to a recipient. In each case, my historic authorization will remain effective as to protected health information that was disclosed prior to expiration/revocation of this Authorization.

I have read and understand the information contained within this Authorization and selected the applicable responses to indicate my agreement and to allow the use and disclosure of my/the patient's medical and/or financial record information as described above.

Add new row

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient / Responsible Party

Date

Patient / Authorized Representative Authorization for Release of certain Protected Health Information

By signing this authorization ("Authorization"), I hereby agree as follows:

I grant Legal Entity Name ("Practice"), acting through the Practice's employees, agents, contractors, or business associates, the right to use, disclose, and publish certain protected health information ("PHI"), including but not limited to my name, biographical information, voice, photograph, video, and/or likeness, including that which is contained within or related to any patient testimonial, including any such testimonial that I may post on social media or review websites (collectively, the "Information"), for the purposes of marketing, public relations, professional consultations, research, education, or publication in professional journals. Any such Information disclosure made by the Practice may be made available to the general public through the posting of the Information on the Practice's websites, social media pages, and through printed advertisements, television, radio announcements, and other promotional publications of the Practice.
I understand that the Practice may use the Information for the purposes outlined in this document and that this may benefit the Practice. I further understand that the Practice does not, and will not ever, owe me any royalty or other amount relating to use of the Information.
I understand that I have no right to inspect or approve of any printed or electronic matter that may be used as described herein and that the matter and materials in which my Information is used may be modified, edited, or combined with other materials. I further understand and agree that the Practice will retain the exclusive right to approve or disapprove of the extent, format, and manner in which my Information may be released. I understand and agree that the Practice will not be liable for any publication or broadcast errors.
I understand that entering into this Authorization is voluntary, that I may refuse to sign this Authorization, and that the Practice will not condition the commencement or continuation of treatment on my decision as to whether to provide this Authorization, nor would my refusal to sign this Authorization affect any payment, enrollment or eligibility for benefits from any source. I further understand that I may revoke this Authorization at any time after signing it by providing written notice that I would like to revoke this Authorization to the Practice at:
Scott Law Ortho Corp
Attention: Privacy Officer
5400 LBJ Fwy, Suite 800 (Tower 1)
Dallas, TX 75240
I understand that my grant of rights to the Practice contained in this Authorization cannot be revoked to the extent that action has already been taken in reliance on this Authorization prior to the date that the Practice receives my written request to revoke this Authorization. This Authorization shall expire ten (10) years from the date of my signature unless I terminate my grant of rights to the Practice contained herein earlier. Such termination of rights shall be on a prospective basis from and after the day on which my revocation is received by the Privacy Officer noted above.
I understand that the Practice will not use or disclose my PHI for the reasons set forth herein beyond the scope of this Authorization without my written consent/authorization or as otherwise permitted or required by applicable law. I further understand that disclosed Information may be subject to re-disclosure by the recipient, including any member of the public, and any such re-disclosure shall not require additional consent on my part.
I hereby waive, authorize, discharge and agree to hold harmless the Practice and its employees, agents, contractors, or business associates and their respective officers, directors, employees, agents, successors, and assigns and anyone authorized by any of them from any and all losses, damages, costs, expenses, rights, claims, demands, liability and actions, that may result from any use of the Information, including any distortion of my likeness, that may occur in the taking, processing, reproduction, publication or distribution of my Information, including without limitation from any claim for libel, slander, defamation, invasion of right privacy/publicity, false light or any other claim arising from or relating to the exercise of rights granted hereunder.
If this Authorization is signed by the authorized representative of the patient and/or dependent child, the terms "I," "me," and "my," shall be interpreted to apply to the patient, as applicable.

Signature of Patient or Patient's Authorized Representative

Print Name

Relationship (if signed by person other than patient)

Date

Short text

Your information will be encrypted.