New Patient Registration

New Patient Registration
Child's Name*

First NameMiddle InitialLast Name
Child's Gender*

MaleFemale
Child's Date of Birth*

MonthDayYear
Child's Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*
Who noticed the Orthodontic concern? Please select all that apply*

ParentChildDentist / Hygienist
Please describe your Orthodontic concerns*

Primary Dental Insurance Information
Does your child have Dental Insurance?*
Insurance Company*
Example: Aetna, MetLife, Delta Dental
Subscriber's Full Name*

First NameMiddle InitialLast Name
Subscriber's Date of Birth*

MonthDayYear
Subscriber's Employer*
Subscriber's ID*
Subscriber's Group ID
Subscriber's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber's Phone Number*
Subscriber's Signature
A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the responsible party. For your convenience, we will gladly assist you in submitting your insurance claim by providing you with the necessary orthodontic form, filling in our part, and mailing it for you. By signing below, you authorize us to submit claims on the patient's behalf.
Signature*

Clear
Date*

Secondary Dental Insurance Information
Does your child have a secondary Dental Insurance?*
Secondary Insurance Company*
Example: Aetna, MetLife, Delta Dental
Subscriber's Full Name*

First NameMiddle InitialLast Name
Subscriber's Date of Birth*

MonthDayYear
Subscriber's Employer*
Subscriber's ID*
Subscriber's Group ID
Subscriber's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber's Phone Number*
Subscriber's Signature
A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the responsible party. For your convenience, we will gladly assist you in submitting your insurance claim by providing you with the necessary orthodontic form, filling in our part, and mailing it for you. By signing below, you authorize us to submit claims on the patient's behalf.
Signature*

Clear
Date*
Should be Empty:

Responsible Party Information