Name
west orthodontics
JEREMY T. WEST D.D.S.
Date
New Patient
Patient or parent to provide information requested below this line.
DO NOT WRITE ABOVE THIS LINE
Name:
Age:
Birthdate:
Sex:
M
F
Address:
City:
Zip:
Phone:
School:
Grade:
Interests:
Responsible Party Information
Please fill out insurance information if applicable.
Father’s / Spouse Name (or self):
Social Security No:
Employer:
Date of Birth:
Insurance Company:
Phone:
Group #:
Email:
Cell Phone:
Mother’s / other (or self ):
Social Security No:
Employer:
Date of Birth:
Insurance Company:
Phone:
Group #:
Email:
Cell Phone:
We also use email and cell phone numbers for reminder purposes.
Person Financially Responsible:
Billing Address:
Dentist:
Physician:
Referred by:
In requesting examination and treatment, I authorize the release of all information, including radiographs relating to examination of treatment, to any insurance companies, review committee, state, or local dental associations. I understand that credit bureau reports may be obtained.
Signature (Parent’s signature if minor):
Date:
Cavity Clearance:
Date:
Initial:
Verified By:
Notes:
Fee Estimate:
Phase 1: $
Phase 2: $
Rx Time Estimate:
Phase 1:
Phase 2:
Welcome to West Orthodontics. We can’t wait to meet you.