• Online Patient Form

  • PATIENT DETAILS

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  • GUARDIAN #1 / INSURANCE INFORMATION

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  • INSURANCE (IF APPLICABLE):

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  • GUARDIAN #2 / INSURANCE INFORMATION

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  • ORTHODONTIC INSURANCE (IF APPLICABLE):

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  • SLEEP / AIRWAY ISSUES

  • DENTAL/MEDICAL HISTORY

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  • SIGNED CONSENT

  • I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

    I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

    I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

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  • By submitting this form you agree to the above mentioned consent statement.

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