Roseburg, OR 97471

541-673-8424

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Child New Patient

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Child New Patient Paperwork

Patient's Full Name: *

Prefers to be called:

What helped you decide to come to The Smile Station? *FriendsFamilyDentistSocial MediaOur WebsiteOnline ReviewsOther

Could you clarify a bit?

Dentist's Name:

Phone:

The following information is for a(n): *AdultChild

Sex: *MaleFemale

Date of Birth: *

Home Phone: *

Cell Phone:

Is texting permitted? *YesNo

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

School Name:

Grade Level:

Is child adopted? *YesNo

Parent's Marital Status: *SingleMarriedDivorcedSeparatedWidowed

Parent / Guardian 1 *FatherMotherStep FatherStep MotherGuardianOther

Full Name: *

Cell Phone: *

Employer: *

Occupation: *

Work Phone:

SSN: *

Email Address: *

Address (if different from patient):

Parent / Guardian 2FatherMotherStep FatherStep MotherGuardianOther

Full Name:

Cell Phone:

Employer:

Occupation:

Work Phone:

SSN:

Email Address:

Address (if different from patient):

Does the patient have siblings? *YesNo

Siblings' Name(s): *

Siblings' Age(s):

Person Responsible for Account: *Parent / Guardian 1Parent / Guardian 2Other

If Other, please provide that person's information below:

SSN: *

Name: *

Home Phone: *

Address (if different from patient): *

Cell Phone: *

Business Phone: *

Contact in case of Emergency

Name: *

Phone: *

Cell #: *

DENTAL INSURANCE:

Do you have Dental Insurance? *YesNo

Ortho Coverage? *YesNoDon't Know

Subscriber's Name *

Birthdate *

Group # *

Subscriber ID *

SSN *

Relationship to patient *

Dental Ins. Company *

Ins. Ph # *

Do you have Secondary Insurance? *YesNo

Ortho Coverage? *YesNoDon't Know

Subscriber's Name *

Birthdate *

Group # *

Subscriber ID *

SSN *

Relationship to patient *

Dental Ins. Company *

Ins. Ph # *

DENTAL HISTORY:

Patient's Dentist Name: *

Date of Last Visit:

Has an orthodontist been consulted previously? *YesNo

Orthodontist's Name: *

Date:

* Please Check if YES -or- select NONE OF THESE for NO:* *Injuries to the face, mouth or teethJaw painTMJDifficulty opening or closing jawClicking or popping jawSensitivity when bitingLip bitingGrinding and/or clenching of teethHistory of wearing a mouthguard at nightSnoringThumb/finger suckingTongue and/or swallowing problemsSpeech problemsTonsils and adenoids removedMouth breathingAny missing or extra permanent teethLoose teeth or broken fillingsLumps or irritated areas in the mouthBleeding gumsCrowns/bridgesHistory of periodontal treatment/diseaseFood collection between certain teethRoot canalsMouth soresCold, hot, or sweets sensitivityNONE OF THESE

Other / Explain:

Is patient frightened or anxious about Orthodontic treatment? *YesNo

Is patient concerned about the appearance of his/her teeth? *YesNo

Reason for consultation (chief concern): *

Has there ever been any orthodontic treatment for any other member of patient's family?ChildSpouseParentOther Family MemberNone

Doctor: *

Stage of Treatment: *

Satisfied with the results? *YesNo

MEDICAL HISTORY:

Is patient's general health good at this time? *YesNo

Comments:

Is patient under the care of a physician at this time? *YesNo

Explain:

Family Physician: *

Date of Last Physical: *

Is patient taking any medication? *YesNo

Medication(s): *

Does patient have any allergies? (penicillin, sulfa, latex, etc.) *YesNo

List allergies: *

Has patient ever had a serious illness or been hospitalized? *YesNo

Explain: *

Has patient ever been advised by physician to take an antibiotic prior to any dental treatments? *YesNo

List antibiotic: *

Does patient have any special problems not listed? *YesNo

Explain: *

Approximate height(ft):

Approximate weight(lb):

Have you recently noticed a growth spurt? *YesNo

Has puberty been reached? *YesNo

DO THEY NOW, OR HAVE THEY EVER HAD ANY OF THE FOLLOWING?

* Please check if YES -or- select NONE OF THESE for NO: * *Heart pacemakerHeart problemsHeart murmurHigh blood pressureLow blood pressureBlood disorders / Bleeding problemsStrokeAnemiaGERD / Acid refluxUlcersEmotional problemsSyndrome/birth defectAutismSensory disorderADD / ADHDHandicap/disabilitesAsthmaAllergiesAllergies to metalAllergies to latexSinus problemsDiabetesGlaucomaArthritisOsteoporosisBisphosphonatesProsthetic (artificial) jointInflammatory rheumatismRespiratory lung diseaseHepatitisTuberculosisRheumatic feverX-ray / Radiation (cancer) therapyAIDS or HIV positiveEpilepsyFaintingCancerHeadaches / MigrainesEarachesSleep apneaImpaired hearingNONE OF THESE

Other / Explain:

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

This office may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.

Patient/Parent's Signature *

Patient/Parent's Printed Name *

Date *

Consent Given By *

I, {text-35} consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by The Smile Station for any lawful use The Smile Station deems appropriate, including for treatment, advertising his/her/its services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all right to my likeness or any image of me obtained by any photographic or digital means by The Smile Station during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.

I understand that any image of likeness of my may be altered prior to use if deemed appropriate by The Smile Station. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used.

I understand that The Smile Station will make all reasonable efforts to safeguard my privacy as required by appliable law, including Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that The Smile Station cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that The Smile Station may use information regarding my health condition, including information regarding my diagnosis, course of treatment, my date of birth and/or age and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image of me.

I understand that The Smile Station may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.

I have read the foregoing in its entirety and understand its terms.

I decline consent to the use of my personal image and likeness.

Patient Name *

Patient/Guardian Signature *

Relationship to Patient (if patient is a minor)

Date

Pediatric Sleep Questionnaire

Did your child have Adenotonsillectomy surgery? *YesNo

Please answer the following questions as they pertain to your child in the past month.

While sleeping does your child:

1. Snore more than half the time? *YesNoDon’t Know

2. Always snore? *YesNoDon’t Know

3. Snore loudly? *YesNoDon’t Know

4. Have “heavy” or loud breathing? *YesNoDon’t Know

5. Have trouble breathing, or struggle to breathe? *YesNoDon’t Know

6. Have you ever seen your child stop breathing during the night? *YesNoDon’t Know

Does your child:

7. Tend to breathe through the mouth during the day? *YesNoDon’t Know

8. Have a dry mouth on waking up in the morning? *YesNoDon’t Know

9. Occasionally wet the bed? *YesNoDon’t Know

10. Wake up feeling unrefreshed in the morning? *YesNoDon’t Know

11. Have a problem with sleepiness during the day? *YesNoDon’t Know

12. Has a teacher or other supervisor commented that your child appears sleepy during the day? *YesNoDon’t Know

13. Is it hard to wake your child up in the morning? *YesNoDon’t Know

14. Does your child wake up with headaches in the morning? *YesNoDon’t Know

15. Did your child stop growing at a normal rate at any time since birth? *YesNoDon’t Know

16. Is your child overweight? *YesNoDon’t Know

This child often:

17. Does not seem to listen when spoken to directly. *YesNoDon’t Know

18. Has difficulty organizing tasks and activities. *YesNoDon’t Know

19. Is easily distracted by extraneous stimuli. *YesNoDon’t Know

20. Fidgets with hands or feet or squirms in seat. *YesNoDon’t Know

21. Is “on the go” or often acts as if “driven by a motor”. *YesNoDon’t Know

22. Interrupts or intrudes on others (ex: butts into conversations or games). *YesNoDon’t Know

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL or DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

_______________________________________________________________________

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth, mouth, and oral health; prescribing medications and faxing them to be filled; prescribing dental appliances and dental prostheses; showing you treatment options; referring you to another dentist for specialty care; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your dental or medical care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personal decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, (we will) (we usually will not) ask you for special permission.
(We will ask for special written permission in the following situations: anything related to HIV/AIDS status, any sale of information, any use of information for marketing or fundraising purposes, and {text-33}.)

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

when a state or federal law mandates that certain health information be reported for a specific purpose;
• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from federal Food and Drug Administration regarding drugs or medical devices;
• disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
• disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
• disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
• uses or disclosures for health related research;
• uses and disclosures to prevent a serious threat to health or safety
• uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
• discloses of de-identified information;
• disclosures relating to worker’s compensation programs;
• disclosures of a “limited data set” for research, public health, or health care operations;
• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
• disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at out office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process it it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:
• Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. We must honor a restriction not to send information to a health care plan regarding any service for which you have already made full payment. To ask for a restriction, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
• Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using Email to your personal Email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
• Ask to see or get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 10 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
• Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or Email shown at the beginning of this Notice.
• Get a list of the disclosures that we have made of your health information within the past six years (or shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
• Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice. be notified by us in a timely manner of any breach of the privacy and confidentiality of your unsecured protected health information, which we will provide to you in accordance with law and take all appropriate measures to address.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our website.

COMPLAINTS

If you think we have not properly respected the privacy of your health information, you are free to complain to us of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or Email shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Notice of Privacy Practices.

Patient Name: *

Signature: *

Date *

PATIENT HIPAA AWARENESS

With my permission, The Smile Station may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to The Smile Station 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. The Smile Station reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of The Smile Station may call my home or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results, among others.

With my permission, the office of The Smile Station may mail to my home or other designated locations any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. This also includes texting appointment reminders.

With my permission, the office of The Smile Station may e-mail my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that The Smile Station restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this, I am allowing The Smile Station to use and disclosure my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

Signature of Patient or Legal Guardian *

Print Name of Patient or Legal Guardian *

Date *

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Roseburg, OR 97471
541-673-8424
[email protected]
Monday and Friday 9am-5pm

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