Welcome
to the Owl ortho

About You

Last
First
MI
MR MRS MS DR
APT/CONDO #:
City
State
Zip
City
State
Zip

Spouse Information

Orthodontic Insurance

Primary
City
State
Zip
City
State
Zip
Secondary
City
State
Zip
City
State
Zip

Payment is due in full at the time of treatment

unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible For all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records at treatment or examination rendered, to my insurance company.

Medical History

Have you ever had any of the following diseases or medical problems?
Are you allergic to any of the following:

Dental History

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. This office reserves the right to verify the credit status of potential patients and/ or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office,use the services of one or more credit reporting services.