Confidential Patient Information

Today's Date:
First Name:
Middle Initial:
Last Name:
Birth Gender:
Patient's Date of Birth:
Parent/Guardian First Name:
Parent/Guardian Last Name:
Cell Phone:
Emergency Contact First Name:
Emergency Contact Last Name:
Emergency Contact Phone Number:
Email:
Home Address:
Address Line 2:
City:
State:
Zip:
Does the patient have any allergies you are aware of?
If you answered yes above, what allergy/allergies does the patient have?
Who is the patient's General/Pediatric Dentist?
What is your chief orthodontic concern?
Has the patient had previous orthodontic consultation or treatment?
If yes, please describe:
Any History of:
If major surgery and/or hospitalization selected, please describe:
If other, please describe:
Any delay in physical or mental development?
Any existing diagnoses:
If other, please list:
Oral Habits:
Please list any sports, hobbies, or musical instruments played:
Please list the name of any friends or family currently in the practice:
How did you hear about us? (choose all that apply)
If other, please list:
Are you utilizing Dental Insurance?
Insurance Company Name (If Delta Dental, Delta of what state?):
Subscriber's First Name:
Subscriber's Last Name:
Subscriber's DOB:
Subscriber's SSN #: (If providing Group # and Member ID instead, field can be N/A)
Group #:
Member ID/Policy #:
All information provided is correct to my knowledge.

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.

Our office is required by law to maintain the privacy of your Protected Health Information (PHI). We are also required to give you notice about our privacy practices, our legal duties, and your rights concerning your protected health information.

I understand that under the Health Insurance Portability and Account Act of 1996 .(HIPAA), I have certain rights to privacy regarding my Protected Health Information (PHI).

I understand that my information can and will be used to:
  • Conduct, plan, and direct my treatment and follow up among the multiple health care providers, who may be involved in the treatment directly or indirectly
  • Obtain payment(s) from third party payers
  • Conduct normal healthcare operations
  • To communicate with you or persons involved in care
Your Rights:
  • You have a right to obtain access to your health information and request copies.
  • You have the right to request a restriction on the use or disclosure of your health information.
  • You have the right to request to receive communications by alternative means or at alternative locations.
  • You have the right to request an amendment to your health information.
  • You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically.

Questions or Concerns: If you have any questions, concerns, or want information about our privacy policy, please contact us.
I certify that I have had the opportunity to review the Notice of Privacy Practices of Kampas Orthodontics PC.
Name of Responsible Party:
Relationship to Patient:
Date:
Signature: