Has Patient reached puberty? - 

Does the patient have a history of: 

 

(It is important to have had a dental examination & cleaning within 6 months prior to starting orthodontic treatment)

Patient referrals are the best compliment to our practice! Thank you in Advance for your trust in us!! 

 

(A parent or legally responsible adult must accompany patient under 18 years of age at initial visit) 

 

(We take great pride in providing the BEST care available) 

 

SECTION A: PATIENT GIVING CONSENT 

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY 

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, healthcare operations, and of the use and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Insoft & Hurst Orthodontics
6700 Crosswinds Dr N, Suite 300B, St. Petersburg, FL 33710
Phone: (727) 384-4511 Fax: (727) 341-0610
yoursmile@braceinfo.com

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Privacy Officer listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature:
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to you to use and disclose of my protected health
information to carry out treatment, payment activities and health care operations.

 

If this Consent is signed by a personal representative on behalf of the patient, complete the following: 

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT 

Include completed form in Patient's Chart

Patient Photo Release Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.

I understand your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my health information.

This release is strictly designed to give permission to Insoft & Hurst Orthodontics, to use my digital patient photos for their website, Social Media, and in office presentation for both educational and promotional purposes. Insoft & Hurst Orthodontics will have permission to use these photos in the manner discussed with me, unless I request the office no longer use them. I understand that by allowing
Insoft & Hurst Orthodontics to use my photos, they are able to share "before and after" images of my teeth to educate and explain procedures and possible results of treatment. Insoft & Hurst Orthodontics will not disclose names or full-face photos. I understand that I have the option to decline this request and
am not obligated in any way to provide permission to use these photos.