Child Medical History

Trail Orthodontics is committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible professional manner.

Patient’s Medical and Dental History (and x-rays as required) are GATHERED:

We collect information from our patients such as names, home addresses, phone numbers, and emergency contact information which is used for the following purposes:

• Contact information is disclosed to third party health providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim or insurance pre-determination on the patient’s behalf.
• Financial information is collected for payment processing purposes. It is not shared with third parties without your consent, unless it is for collection purposes.
• We collect information from our patients regarding health history, family health history, physical conditions, and dental treatments for diagnosing orthodontic conditions and providing orthodontic treatment.
• At times it may be necessary to contact your dentist and/or dental specialist to request copies of x-rays that were taken at their office.

I hereby authorize the release of Orthodontic records and/or x-rays from my dentist and/or dental specialist.

Patient’s Medical and Dental History (and x-rays when requested) is DISCLOSED:

• To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement for payment of all or part of the cost of orthodontic treatment has requested us to submit a claim or insurance pre-determination on the patients’ behalf.
• To other dentists and/or dental specialists – When we are requesting a second opinion and the patient has given their consent to do so.
• To other dentists and/or dental specialists – With the patient’s consent, has been referred by us to the other dentist or dental specialist for treatment.
• To other dentists and/or dental specialists – Where those dentists have asked us, with the consent of the patient, to provide a second opinion.
• To healthcare professionals such as physicians, with the consent of the patient, has been referred by us to the other health care professionals for either second opinion or treatment.
• To release information for medical–legal reports as required by law.

I hereby authorize the release of Orthodontic records and x-rays to my dentist and/or dental specialist.