We would Like to welcome You and your child to our office. Our mission is to enhance the lives of our patients and their families by providing exceptional orthodontic care with excellent customer a service in. a safe and inviting atmosphere.

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Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand the information that I have given today is correct and to the best of my knowledge. I also understand that is information will be held in strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the staff to perform any necessary services that the patient may need during diagnosis and treatment. I understand where appropriate, Credit bureau reports may be obtained.

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First

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Previous Address(If less than three years):

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Saylor & Murphy Orthodontics

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We would Like to welcome You and your child to our office. Our mission is to enhance the lives of our patients and their families by providing exceptional orthodontic care with excellent customer a service in. a safe and inviting atmosphere.

Tell Us About Your Child

Responsible Party

Emergency

Dental Insurance

Secondary Insurance

Growth information for Patients Under 16 Years of Age

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Does / did your child have any of the following habits?

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Has your child ever had any of the following?

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Growth information for Patients Under 16 Years of Age

Third Child Information

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Does / did your child have any of the following habits?

Growth information for Patients Under 16 Years of Age

Saylor & Murphy Orthodontics

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I have received a copy of this office’s Notice of Privacy Practices.

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