Morrell Orthodontics
200 Marter Ave Suite 500
Moorestown, NJ 08057

Morrell Orthodontics New Patient Form

Save time at the office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.

Patient Information
Responsible Party Information (if different from the Patient*)

*You do not need to fill out this section if the Patient is the Responsible Party

Dental Insurance Information
Emergency Contact Information
Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check atleast one field
Dental History
Electronic Signature

By electronically signing and clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. I understand it is my responsibility to inform this office of any changes to the patient's medical status. All information is confidential and is accessed only via a secure, encrypted interface. I give Morrell Orthodontics permission to perform the necessary dental services that the patient may need. I agree to the terms of the Privacy Policy with Morrell Orthodontics. A copy of this policy has been made available to me upon request.

Please check atleast one field
What is Most Important

We recognize that each patient family has individual needs and expectations.

Our Goal is to Meet and Exceed Yours!

HIPAA Consent
Photographic / Media / Social Media Consent
Authorization for Release of Orthodontic Records and X-Rays:
Authorization for Cell Phone and Email Use
Please check atleast one field

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained only with the responsible party's permission.

Morrell Orthodontics may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.