Coastal Carolina Orthodontics

Adolescent and Adult Orthodontics
  • W. Alex Willis. D.D.S.. M.Sc.O. Logo
  • Todd A. Fischer, D.M.D., M.S. Logo
  • Richard J. Vanek. D.D.S.. M.Sc.O.
  • Benjamin J. Richards. D.M.D. Logo
  • Raymond C. Ball. Jr.. D.D.S.. M.S. Logo
  • David G. Walker. D.D.S.. M.S. Logo

www.smilemakersnc.com

Please fill out this form to the best of your ability prior to your initial appointment. There are two ways to complete this form:

Electronically – Fill out the fields below and submit electronically by selecting the “submit” button at the bottom of the form

Manually – Print and bring a completed form to your initial visit

We are happy to answer any questions you have regarding the requested information at the time of your appointment.

Adolescent Patient Begin Here

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Adult Patient Begin Here

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Dentist & Physician Information

Nearest Relative Not Living With You

COASTAL CAROLINA ORTHODONTICS

17 OFFICE PARK DRIVE

JACKSONVILLE. NC 28546-3219

910-353-5234

carteret medical center

3606-A Medical Park Court

morehead city, nc 28557-4347

252-726-1137

stonebridge professional center

98 stonebridge trail

havelock, nc 28532-9553

252-447-1181

Insurance Information


Medical History

Dental History

Acknowledgement of Receipt of Notice of Privacy Practices

Patient, Parent or
Guardian’s Signature

“To sign electronically, place your curser in the box, click your mouse button and hold down while signing your name to the best of your ability.”


I request that payment of authorized benefits be made either to me or on my behalf to Willis, Vanek, Ball, Fischer, Richards & Walker, PA, for any services furnished me by that provider, realizing i am responsible to pay noncovered services. I hereby authorize any holder of information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services.

“To sign electronically, place your curser in the box, click your mouse button and hold down while signing your name to the best of your ability.”