Adult Health History

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Spouse Information

Person Responsible for Account:

Orthodontic Insurance

Primary

Secondary

In the event of an emergency, is there someone who lives near you that we could contact?

Medical History

Please list each one:

Add an additional medication

For Women:

Please list any serious medical condition(s) that you have ever had:

Add new serious medical condition

Dental History

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

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 this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

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

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

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

Acknowledgement of Receipt of Notice of Privacy Practices

*You may refuse to sign this acknowledgement*

Please VIEW-READ-PRINT our Notice of Privacy Practices by clicking HERE

⠀ ⠀ ⠀ ⠀ ⠀ ⠀ ⠀ ⠀ ⠀I,

have received a copy of Wermerson Orthodontics Notice of Privacy Practices.

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

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the patient named herein

For Wermerson Orthodontics office use, in the event, the Notice of Privacy Practices isn’t signed. We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practice, but acknowledgment could not be obtained because:

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