OMI - Health History

O-M-I Orthodontics

Online Information Submission: Welcome To Our Practice!

Because your time is very valuable we continually change our procedures to honor your time with us, this system was developed to save you time on the phone and at our office. Please complete the following registration and health history below online! It takes but a few minutes from the comfort of your home to fill out this confidential form where you have access to all your important information. When completed, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.

Patient Information:

(Section 1 of 7)

Items marked with asterisk (*) must be completed.
First Name*
Middle Name
Last Name*
I prefer to be called (Nickname)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone (Very Important)
Home Phone*
Work Phone
Email Address*
example@example.com
Birth Date

MonthDayYear
Date
Gender

MaleFemale
Social Security Number (US Only)
If patient is a minor, give parent's or guardian's Name
Whom may we thank for referring you to our office? (Our best patients come from referrals and we want
Whom may we thank for referring you to our office?
(Our best patients come from referrals and we want to thank our referrers!)
Other Family Members seen by us

Responsible Party Information:

(Section 2 of 7)

Items marked with asterisk (*) must be completed.
Full Name*
Relationship to Patient
Birth Date

MonthDayYear
Date
Social Security Number (US Only)
Employer
Number of Years Employed
Occupation
Email Address
example@example.com
Home Phone
Work Phone
Cell or Other Phone
Spouse's Name
Birth Date

MonthDayYear
Date
Social Security Number (US Only)
Employer
Number of Years Employed
Occupation
Email Address
example@example.com
Home Phone
Work Phone
Cell or Other Phone
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long at this address? (in years)
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Dental Insurance Information:

(Section 4 of 7)

Items marked with asterisk (*) must be completed.
Subscriber's Name
Subscribers's Date of Birth
Subscribers's Social Security Number (U.S. only)
Insurance Company
Insurance Phone Number
Identification Number
Group Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have dual coverage?
Secondary Subscriber's Name
Secondary Subscriber's Date of Birth
Secondary Insurance Phone Number
Secondary Insurance Company
Secondary Insurance Group Number
Secondary Insurance Identification Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Information:

(Section 5 of 7)

Items marked with asterisk (*) must be completed.
Name of the nearest relative not living with you
Phone Number
Complete Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please check any of the following which apply to you.