• ORTHODONTIC PATIENT INFORMATION

  • WELCOME TO OUR OFFICE
    The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examinathon in our office, In order for the onthodontist to thoroughly diagnose any condition, he must have accurate background and health information on which to base his decisions. This informaion, important for your health, is confidential, Please circle the appropriate responses where indicated.

  • PATIENT INFORMATION

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  • FAMILY STATUS

  • INSURANCE INFORMATION

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  • Occasionally information is shared with a family dentist or other specialists. By providing us your email address, we can share this information with you.

  • PERSON RESPONSIBLE FOR ACCOUNT

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  • SPOUSE/OTHER PARENT INFORMATION

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  • SECOND INSURANCE CARRIER INFORMATION

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  • PATIENTS MEDICAL AND DENTAL HISTORY

  • Does the patient

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  • PATIENTS ATTITUDE TOWARD TEETH, FACE AND ORTHODONTIC TREATMENT:

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  • I understand that where appropriate, credit bureau reports may be obtained.
    I authorize release of any information relating to my insurance claim.
    I understand that I am responsible for all costs of orthodontic treatment.
    I hereby authorize payments of insurance benefits otherwise payable to me, directly to Dr. Kurshuk.

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  • Should be Empty: