Infant Intake Form — Central Florida Specialists

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Infant Intake Form

Child Intake Form

Adult Intake Form

Infant Intake Form

Child Intake Form

Adult Intake Form

Infant Intake Form

Child Intake Form

Adult Intake Form

Today's Date *

MM

DD

YYYY

Infant's Name *

First Name

Last Name

Infant's date of birth *

MM

DD

YYYY

Parent/guardian name *

First Name

Last Name

Phone *

(###)

###

####

Address. *

Email *

Who referred you to our office? *

Any other specialists? *

Main concern/reason for referral *

Any hospitalizations/or surgeries? Please explain. *

Is your child currently taking any medications or supplements? Please explain. *

Any concerns with the following: *

Check all that apply:

Breast feedings

Bottle feedings

Open mouth posture

Reflux

falling asleep or fatiguing while eating

Tongue or lip restriction

Birth History

Any difficulties noted before, during, or after birth? Please describe.

Length of pregnancy (weeks?

Birth weight

Were their sucking or feeding problems at birth? Please describe.

Is there a family history of mouth breathing?

Is their a family history of tongue or lip ties? Please explain.

What specialists have you seen?

Lactation consultant

Osteopathic specialist

Dentist

Airway specialist

Pediatrician's name

Pediatrician's phone number

(###)

###

####

Pediatircian's fax number

(###)

###

####

Thank you!

HIPPA Private Practices Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. HIPAA provides certain rights and protections to you as the patient on who may see or be notified of your Protected Health Information (PHI).

Patient Name *

First Name

Last Name

By checking off the boxes you are stating you understand the following policies: *

Your confidential information will not be used for marketing or advertising of products, goods, or services.

We agree to provide patients with access to their records in accordance with state and federal laws.

Patient information will kept confidential except as is necessary to provide services to your care as necessary.

It is the policy of this office that you come to your appointed session unless canceled or rescheduled within a day of the session.

You agree to bring any concerns you have or complaints to the attention of your clinician or Meric O'Grady.

This practice works with other physicians outside this office. They have access to personal health information, but abide by the confidentiality rules of HIPPA.

You agree to inspections of the office and review of documents, which may include personal health information by insurance companies and government agencies such as, but not limited to (CMS, Sunshine, Tri-Care, etc.) in performance of their duties.

You have the right to request restrictions in the use to protect your personal health information and request changes in some policies used at this practice dealing with your PHI. However, we are not required to alter internal practice policies to conform to your request.

We may modify any of these policies to better services the needs of the patient and or practice.

I hereby do/do not authorize, Central Florida Specialists and affiliates, employees, or agents to release any personal health information (e.g., information relating to the diagnosis, records, treatment, claims payments, and healthcare services) provider or to be provided to me to: *

I hereby authorize

I herby do not authorize

Parent/Spouse/Relative *

Referring Provider *

Primary Care Doctor *

Other Consultants

*This release of information will remain in effect until terminated by me in writing*.

I, ______________ do hereby consent and acknowledge my agreement to to the terms set forth in this HIPPA Private Practices Form and any subsequent changes in office policy. *

Signed by: *

Relation to Child: *

Date Signed *

MM

DD

YYYY

Thank you!