• Adult Medical/Dental History Form

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  • Dental Insurance

    In order to verify ortho coverage and retrieve benefits, we must have member ID or social if no member id was provided.
  • If yes, please provide details below.

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  • Secondary Insurance

  • If yes, please provide secondary insurance details below.

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  • Dental History

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  • Medical History

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  • Do you have now, or have you ever had any of the following?

  • HIPAA Consent

  • I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.
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  • Should be Empty: