North Bend: 425-888-1896 | Snoqualmie: 425-831-0386 | Maple Valley: 425-413-2121 | Enumclaw: 360-625-9868

Our team at Kirby Nelson Orthodontics knows that you are busy, so we want to make sure your visit with Dr. Nelson, Dr. Katz, or Dr. Roberts is productive and time-efficient. Our patient forms can be completed and easily submitted electronically to our office from this page.

We encourage you to complete the new patient forms prior to your complimentary orthodontic consultation, allowing us to spend the entire time focusing on you and giving you sufficient time to ask any questions you may have.

You may also print the forms, fill them out by hand, and bring them into the office with you.

We look forward to meeting you soon!  If you have any questions or need help locating or completing the forms, please feel free to call us in North Bend, Snoqualmie, Maple Valley, or Enumclaw, Washington. We are here to help in any way that we can!

Patient Information
Medical/Dental History
Does patient have any illness or physical condition we should know about?: Yes No
Has patient been to a physician in the last 6 months?: Yes No
Has patient been to a dentist in the last 6 months?: Yes No
Have any teeth (including "baby teeth") ever been extracted by your dentist?: Yes No
Have any permanent teeth ever been injured or loosened by a fall?: Yes No
Are any of the following conditions present in patient's present or past history:
If patient is a minor, please answer the following questions:
Any noticeable difficulty in breathing through the nose?: Yes No
Does the patient have speech problems?: Yes No
Has patient had speech or tongue therapy?: Yes No
Has thumb sucking been a habit after the age of 6?: Yes No
Has tongue thrust been a habit after the age of 6?: Yes No
Has mouth breathing been a habit after the age of 6?: Yes No
Responsible Party Information(Same as Patient)
If patient is a minor please fill out the following:

Contractual financial arrangements for service fees will be subject to approval of credit and may require a credit report.

Dental Insurance Information
Do you have secondary dental insurance? Yes No


Statement Of Privacy Practices

Our office is dedicated to protect the privacy rights of our patients and the confidential Information entrusted to us. The commitment of each employee to ensure that your health Information Is never compromised Is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always Inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Wash_ington. This Includes Issues relating to your treatment, payment, and our health care operations. Your personal health information wm never be otherwise given to anyone-even family members-without your written consent. You, of course, ·may give written ·authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records Is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health Information will never be Improperly disclosed or released.

Collecting Protected Health Information

We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected.from you, we may obtain information from third parties if It is deemed necessary. Regardless of the source, yo":'r personal Information will always be protected to the full extent of the law.

Disclosure of your Protected Health Information

As stated_ above, we may disclose Information as required by law. We are obligated to provide lnformation to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines and postcards.

Patient Rights

You have a right to request copies of your healthcare information; to request copies In a variety of formats; and to request a list of instances In which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health Information.

I acknowledge that I have received the Statement of Privacy Practices for the offices of Kirby Nelson Orthodontics.

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