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PATIENT INFORMATION
Street, City, State, Zip Code
Street, City, State, Zip Code
ADDITIONAL CONTACT INFORMATION
Financially Responsible Party (if not patient)
Street, City, State, Zip Code
Emergency Contact
Street, City, State, Zip Code
DENTAL INSURANCE INFORMATION
Primary Insurance
Street, City, State, Zip Code
Secondary Insurance (if applicable)
Street, City, State, Zip Code
Medical History
(female only)
DENTAL HISTORY
RELEASE AND WAIVER

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

Patient Signature:

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Patient Signature: