Patient Information

Patient Information

Gender








 

Phone Type 

 

Phone Type



Spouse/Emergency Contact Information

Marital Status









Insurance Information






















Dental History


How did you hear about our Practice?


Have you visited an orthodontist before?


Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?

Do you like your smile?

Medical History

Are you currently being treated by a physician?




Do you have any allergies/sensitivities to medications or latex?

Are you currently taking any prescription or over-the-counter medications?


 


 

Authorization

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 of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

In order for us to offer you the best possible payment plan options, this office verifies the credit status of potential patients and/or parents of potential patients prior to extending credit for treatment fees by using the services of one or more credit reporting services.




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