We look forward to seeing you:

We would appreciate you arriving 10 minutes before
the appt time with this form completed.

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Jeffery C. Summers, DMD
ADULT FORM
Please take this time to tell us about yourself.
First
Middle
Last
EMPLOYER INFORMATION
SPOUSE INFORMATION
INSURANCE
Primary Dental Insurance
Fee Expectations


PERSON RESPONSIBLE FOR ACCOUNT
GENERAL DENTIST
4207 East North St. Greenville, SC 29615

phone (864) 244-7545
fax (864) 244-7767

www.summersortho.com
MEDICAL HISTORY
A complete history is vital for a proper orthodontic evaluation.
Have you ever had any of the following diseases or medical problems? (Please circle all that apply.)
MEDICAL ALERT INFORMATION
DENTAL HISTORY
Appearance
Function
Habits