I grant permission for Dr. Portalupi and his team to perform an orthodontic evaluation.

I give Portalupi Orthodontics permission to take Diagnostic imaging as needed to better assess the orthodontic needs. I understand that some imaging may have diagnostic information beyond the scope of that of typical orthodontic training. I have the option of requesting a referral of the imaging to a Radiologist for more in-depth evaluation at an additional fee. There will not be a charge for the imaging at the time of the visit. Fees for imaging will be included in the Records fee if and when treatment is accepted.

I understand that Dr. Portalupi adheres to HIPAA guidelines to protect patient privacy. In spite of best efforts, it may not be possible to guarantee 100% that leaks of private information cannot occur. There is a HIPAA information sheet for you to view at the Front Desk which you may read upon your arrival.

In order to assess airway issues such as possible sleep apnea, oversized adenoids and tonsils, chronic nasal congestion, please answer “yes” or “no” below: Do you have insomnia, wake up tired from a night’s sleep, frequently feel drowsy, or nod off while driving?