• Health History Form

  • Submit Your New Patient Forms to Miller Orthodontics!!

    Save time at the our office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.

    Items marked with asterisk (*) must be completed.

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  • RESPONSIBLE BILLING PARTY #1

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  • RESPONSIBLE BILLING PARTY #2

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  • Dental Insurance Information

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  • Medical Health 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.

     


  • Dental History

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

  • HIPAA Disclosure

    HIPAA Privacy Notice
  • Miller Orthodontics is obligated under the HIPAA Act to protect the privacy of protected health information (PHI) and to provide you with a notice of ourprivacy practices. You may request a copy of our privacy practices at anytime. For more information about our privacy practices, or for additional copies, please contact us using the information available on this notice.I consent to have Miller Orthodontics use and disclose my PHI forpayment, treatment and healthcare operations purposes, and for suchother purposes that are permitted under HIPAA or other Federal or State law without my written authorization

  • Photo Disclosure

    Privacy Notice
  • Clear
  • By typing your name in this box, you are signing this document with a digital signature.

    By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface. Submit

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