• Patient Information

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  • Responsible Party Information

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  • If patient is under 18, please complete this section.

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  • Dental Insurance Information

  • Primary Insurance Information

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  • Secondary Insurance Information

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  • Emergency Information

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  • Medical History

  • Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

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  • Please check any of the following which apply to you, and add any relevant comments.

  • Please check any of the following that you have had or currently have:

  • Dental History

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  • Over office is HIPPA compliant and is committed to meeeting or exceeding the standards of infection control mandated by OSHA, the CDC , and the ADA. I authorize the dental staff to perform the necessary orthodontic services my child or my self may need.

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