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  • English (US)
  • Spanish (Latin America)
  • NEW PATIENT REGISTRATION

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  • PATIENT INFORMATION

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  • FINANCIAL RESPONSIBILITY PARTY INFORMATION

    If patient is a minor (under 18), a responsible party other than "self" is required.
  • Responsible Party Information

    Please fill out if responsible party is not "self."
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  • PATIENT MEDICAL AND DENTAL HISTORY

  • PATIENT DENTAL HISTORY

  • DENTAL INSURANCE INFORMATION

    If you have dental insurance that may need verification, please provide the requested information below as accurate as possible. A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the patient’s account and the patient or person responsible for the account is responsible for payment of all fees incurred. We will gladly assist you in submitting insurance claims pertaining to any charge for care in our office.
  • PRIMARY INSURANCE INFORMATION

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  • SECONDARY INSURANCE INFORMATION

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  • I understand that I am responsible for payment of services rendered and also responsible for paying any copayments and deductibles that my insurance does not cover. In the event of a default on agreed upon payment arrangements, I am responsible for reasonable collection costs.

    I have truthfully answered all of the above questions and agree to inform Kind Orthodontics of any changes in my medical or dental history. In addition, I authorize Dr. Emerald Nguyen or Dr. Nga Hoang to perform a complete orthodontic evaluation.

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