Thank you for scheduling an appointment at Montgomery Orthodontics. Prior to your first appointment, please complete Sections 1 - 9 of this form.
The information you provide will be sent to our office with secure encryption. Our office complies with HIPAA Privacy requirements (see Section 7 of this form). Completion of this form prior to your appointment will save you time during your visit to our office and will allow us to verify your insurance coverage.
You can expect that it will take approximately 10 minutes to complete this form. If you have any questions, please call our office at (609) 688-1611.
We look forward to seeing you.