Orthodontic
Patient Forms

Orthodontic
Patient Forms

Whether you're preparing for your first appointment or updating your health history, please take a moment to complete and submit the Health History form using the link below.

 

New Patient Health History Form

 

Health History Form Update

 

Patient Acknowledgement of Notice of Privacy Practices

 

Signing a Contract

PATIENT ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

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ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have been provided with a copy of the Notice of Privacy Practices (NPP) for AB Orthodontics, Inc., effective January 1, 2026.

I understand that this Notice describes how my protected health information (PHI) may be used and disclosed, how I may access my information, and my rights regarding the privacy of my health information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended, and applicable federal and state law.

I understand that the Notice includes specific information regarding:

  • My privacy rights under HIPAA
  • How my dental and medical information may be used for treatment, payment, and health care operations
  • Special privacy protections for certain sensitive information, including substance use disorder records (42 CFR Part 2) and reproductive health information
  • How to file a complaint if I believe my privacy rights have been violated

I understand that AB Orthodontics, Inc. reserves the right to change its Notice of Privacy Practices and that a current copy will be available in the office, on the practice website (if applicable), and upon request.

PATIENT INFORMATION

Patient Name(Required)
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