Adult New Patient Form

ACCORDING TO THE FOLLOWING SCALE, CHOOSE THE APPROPRIATE NUMBER VALUE TO REPRESENT HOW LIKELY YOU ARE TO FALL ASLEEP DURING THE DAY IN THE FOLLOWING SITUATIONS.

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment. It is my responsibility to inform this office of any changes in my personal information or health status. I will not hold mBrace Orthodontics or the staff responsible for any errors or omissions that I have made in the completion of this form.
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dr. Shireen Irani and mBrace Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility and available upon request
Dr. Shireen Irani and mBrace Orthodontics reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices upon request.