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.

Emergency

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Dental Insurance

Orthodontic Coverage?

YesNo

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Secondary Insurance

Orthodontic Coverage?

YesNo

Insurance Member ID:

Insurance Co. Name:

Insurance Co. Address:

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Policy Owner's Name:

Relationship to Patient:

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Second Child Information

Third Child Information

Acknowledgement of Receipt of Notice of Privacy Practices

Saylor & Murphy Orthodontics

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

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I have the right at any time to revoke this Acknowledgement for any reason. I have the right to sign this portionat a later time/dateof my choice to revoke my Acknowledgment.

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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.

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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

Has your child ever had any of the following?

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

Second Child Information

Tell Us About Your Child

Has your child ever had any of the following?

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

Growth information for Patients Under 16 Years of Age

Third Child Information

Tell Us About Your Child

Has your child ever had any of the following?

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

Growth information for Patients Under 16 Years of Age

Saylor & Murphy Orthodontics

* You May Refuse to Sign This Acknowledgment*

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

Right to Revoke: