• Insurance Information

    Submit your health history form online to your orthodontist today. Save time at the orthodontist's office and fill out your insurance 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.
  • PLEASE NOTE: The requested information relates to the insurance subscriber, not the patient. Please review each question carefully before answering.

  • In order to assist in determining your orthodontic insurance benefit, the following information is necessary:

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  • If there is dual coverage or another dental plan, please complete the following section:

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    Pick a Date
  • Signatures

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