700 W. Cherry Street, Suite C, Sunbury, OH 43074
740-936-5003
Your first visit with our orthodontist, Dr. Michele Renick, is a multi-stage process.  We ask you as the new patient to arrive 15 minutes early for your appointment in order to complete your new patient paperwork. At Renick Orthodontics, Dr. Michele Renick wants your first visit to be as easy and efficient as possible. For this reason, we give our patients the option of completing their forms either at the office in Sunbury, Ohio, or by downloading them and completing the forms at home. This second option of downloading the forms allows you to proceed at your own pace and in the privacy of your own home. You have the opportunity to find phones numbers and addresses to complete your paperwork without feeling flustered.
By providing you, the patient, the ability to get a head-start on the paperwork, we are able to simplify the first step to creating your new smile. If you have any questions about the information required on your patient forms, please call 740-936-5003 to speak with a member of our team. We are more than happy to walk you through the forms as needed!
Please use the following links to quickly find the forms you need:
FORMS FOR ALL PATIENTS
Our office requires certain forms for all of our patients to fill out. The required forms are indicated by the ** in red below.
HIPAA FORMS FOR THE NEW PATIENT APPOINTMENT
**HIPAA PRIVACY POLICY
Please take a moment to review our HIPAA privacy policy. Here at Renick Orthodontics, we take steps to keep your medical information private.
**HIPAA ACKNOWLEDGEMENT AND CONSENT
This form acknowledges that you have access to our HIPAA Privacy Policy. Please fill in the top of the form, print your name, and sign and date the top part.
The bottom section gives us permission to use the pictures we take for the office. We need a YES or NO for each item. Sometimes we post pictures of patients at events we participate in. In addition, patient education refers to presenting a similar case to other patients, education slideshows, or for lectures geared toward professional advancement. Please print your name, and sign and date at the bottom. Generally, we don’t reveal names but may use initials or first names only.
**HIPAA RELEASE – FOR MINOR PATIENTS
At Renick Orthodontics, we understand how busy lives can be. The HIPAA Release form allows someone other than the parent or legal guardian to accompany a minor patient to their appointment. Oftentimes, a grandparent or older sibling will bring a patient to the office. This form allows us to discuss important information with the person bringing the patient. This may include, but is not limited to, oral hygiene, and/or treatment decisions and instructions. Please fill out the form, print your name, and sign and date at the bottom.
FORMS FOR THE NEW PATIENT APPOINTMENT
**NEW PATIENT INFORMATION SHEET (PLEASE CHOOSE THE APPROPRIATE ONE)
NEW PATIENT INFORMATION FOR MINOR PATIENT
This form provides us with patient information for your child.
OR
NEW PATIENT INFORMATION FOR ADULT PATIENT
This form provides us with information about you, the patient.
**MEDICAL AND DENTAL HISTORY FORM
At Renick Orthodontics, we strive to provide the best overall care to our patients. The medical and dental history of a patient can provide vital information needed for future treatment.
Please fill out the form, print your name, and sign and date at the bottom. If you need to provide further information, you may provide it on an additional blank piece of paper. Please detail any surgeries and/or medications the patient takes and the reasons for them.
FINANCIAL FORMS
**SIGNATURE ON FILE FORM
The Signature on File form serves two purposes.
The top half of the form allows us to submit insurance claims on your behalf. Even if you have no insurance at the start of treatment, we recommend you fill out the form in the event that you pick it up at any point during treatment. Please sign and date the top half of the form.
The bottom half of the form is for our patients who have chosen to take advantage of our in-house, no interest installment plan. Please fill out the appropriate information and sign and date at the bottom. Please DO NOT write down your card account number. For the safety and security of our patients, we use a third party payer and we DO NOT keep account information on file in our office.
