Patient Name *
Social Security NumberBirth DateDrivers Licence NumberHome AddressCityStateZipPrimary Phone Number
Secondary Phone Number
E-mail AddressEmployers Name
Occupation
Person(s) OK to release appointment or medically related information to concerning you.Relation
General DentistLast Visit
Name of person referring (if applicable)What are the main concerns you would like orthodontics to accomplish?
When?Reason?
If so, explain:
ReasonPhysicianLast VisitPhone
If yes, please list allergies:
Please list, with dosage:Have you had any serious illnesses or operations? If yes, describe:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.