• New Patient Registration Form

  • PATIENT INFORMATION

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  • RESPONSIBLE PARTY INFORMATION

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  • If No, please provide the following information for the other parent:

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  • DENTAL INSURANCE INFORMATION

    Please let us know if you have dual insurance coverage.
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  • MEDICAL HISTORY

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  • I give permission for Dr. Held to evaluate me for orthodontic treatment.

  • Clear
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  • If minor, I give permission for Dr. Held to evaluate   *   for orthodontic treatment:

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  • Should be Empty: