Orthodontic Patient Portal Access Request Form

Orthodontic Patient Portal Access Request Form
Request access to your orthodontic patient portal by providing the required information below. All information will be used solely for verifying your identity and setting up secure portal access.
Patient’s Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address (for portal login and notifications)
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Relationship to Patient
Other
Preferred Username for Portal Access
Last Orthodontic Appointment Date (if known)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Orthodontic Provider’s Name (Doctor/Practice)
Should be Empty: