ASHMORE ORTHODONTICS Adult Patient Registration

ASHMORE ORTHODONTICS

Adult Patient Registration Form
Today's Date

Month Day Year
Date
Name
Gender at birth / gender identity
Nickname Preferred
Date of Birth

Month Day Year
Date
Age
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear of us?
Dentist's Name
Physician's Name
Employer
Physician's Phone #
Work #
Spouse's Name
Home #
Cell #
Email
example@example.com
SS#
Spouse's Employer
Spouse's cell#
Spouse's Email
Spouse's SS#
Please tell us about your interests, sports, or hobbies:
Have you ever had orthodontic treatment before?

YES NO
Has any other family member received orthodontic care?

YES NO
Do You have orthodontic insurance?

YES NO
Would you like our office to bill your insurance for you?

YES NO
If yes, please let the front desk know as soon as possible and they will be happy to gather the necessary information to process your claims for you

We keep a record of the health care services we provide to you. You may ask us to see and copy that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it at our front desk.
Emergency information: Name of nearest relative or friend not living with you
Phone #
Address
Your Signature:

Clear
Date:

Month Day Year
Date
Should be Empty: