Mattingly & Howell Orthodontics : Adult patient form Logo

  • Patient Information


  • Parent/Guardian Information -1


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  • Parent/Guardian Information -2


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  • Emergency Contact Information

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  • Dental History

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  • Medical History

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  • Dental Insurance Information - primary

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  • Dental Insurance Information - secondary

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  • 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 child's dental status.

    I hereby authorize the release of any information pertaining to my child's dental 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.

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