Welcome
to the orthodontist

A beautiful smile is a wonderful asset. Please fill out this form completely. The better we communicate, the better we can care for you.

1About You

LAST
FIRST
MI
City
State
Zip
City
State
Zip

2Spouse Information

3Orthodontic Insurance

Primary
Secondary
in the event of an emergency, whom should we contact?

4Medical History

4Medical History Cont.

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

5Dental 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 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.

Thank you for filling out this form completely.

!

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 this office, use the services of one or more credit reporting services.


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.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.