CHILD INFORMATION

Please tell us a little about yourself

FAMILY INFORMATION

Parent # 1

Parent # 2

CHILD’S HEALTH HISTORY

CHILD’S DENTAL HISTORY

PATIENT PHOTO / VIDEO RELEASE FORM

This release is designated to give permission to Dr. Kimi S. Caswell, D.D.S., M.S. to use my photos / videos for educational and promotional purposes. I allow my digital patient photo / video series as well as any photos / videos taken in-office or at patient appreciation events to be shared with others by means of internet and print media including but not limited to: our business website, social media websites and print advertising. Dr. Caswell has permission to use my photos / videos in this manner unless I request that she no longer use them. 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 / videos.

I allow Dr. Kimi S. Caswell, D.D.S., M.S. to use my photos / videos for educational and promotional purposes.

Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payer, (insurance carriers etc.).
  • Conduct normal healthcare operations.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this practice has the right to chance its Notice of Privacy Practices from time to time and that I may contact this practice at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Please sign here:

By clicking submit you are agreeing to our privacy policy