HIPAA & Informed Consent

Part A: The Patient

*Name:
Parent or Guardian:

Part B: Acknowledgement of Receipt of Privacy Practices Notice -(located on our website)

I, , acknowledge that I have received a Notice of Privacy Practice from Richardson Orthodontics.
Signature:
Date:
Relationship to Patient (if applicable):
This acknowledgement of receipt will become part of the patient's record.

Part C: Your Protected Health Information Designees

Please list below those individuals (designees) with whom we can discuss your health information. This person (designee) will also be able to call the office on your behalf. For example: if you are 18 or above, and your parents are financially responsible for your treatment please list them.
Please print the name and relationship to you/patient of each designee below:
Designee Name:
Relationship to Patient:
Designee Name:
Relationship to Patient:
Designee Name:
Relationship to Patient:

Part D: Informed Consent for Initial Orthodontic Evaluation

In the vast majority of orthodontic cases, significant improvements can be achieved with informed and cooperative patients. Orthodontic treatment is an elective procedure and it, like any other treatment of the body, has certain inherent risks and limitations. These seldom prevent treatment, but should be considered before beginning treatment. Please feel free to ask any questions at any time.
For the initial evaluation, I consent to the taking of intraoral photographs, x-rays, review of my medical and dental history, and a comprehensive oral evaluation by the doctor. I certify that I have read or had read to me the contents of this from and do understand and realize the risks and limitations involved.
Signature:
Date: