Adult New Patient Form &#8211; Secure Online Forms

Adult New Patient Form

Submit your health history form online to your orthodontist today. Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex**
Birthdate*

MonthDayYear
Date
Social Security #
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Employer
Work Phone
Please enter a valid phone number.
Email
Spouse's Name
Spouse's Employer
Dentist
Referred By:

Signatures
Accuracy*

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.
Insurance*

I authorize this office to verify my/my child's insurance benefit prior to my appointment.
Payments*

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
Signature*

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.
Signature

Clear
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!
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Adult New Patient Form