• Yao Orthodontics

    New Patient Form
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  • Information Must Be Filled Out Completely
  • Custodial Parent Information

    Patient Information
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  • Additional Parent Information

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  • Primary Orthodontic Insurance

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    Pick a Date
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  • Secondary Insurance
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    Pick a Date
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  • What are the main concerns you would like orthodontics to address?

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    Pick a Date
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  • Please list an emergency contact not living with you
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  • Agree to Terms

    I understand that the information I have given today is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I also authorize Yao Orthodontics to perform the necessary orthodontic services my child may need. I further authorize that photos taken during treatment may be used for professional consultations and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.

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