_2017 Adult Registration Form – Ortho

Patient Information

Gender:
Phone Type

Spouse / Partner Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Have you visited an orthodontist before?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you currently or have you ever had any of the following habits (check all that apply):

Medical History

Do you have any allergies/sensitivities to medications or latex?
(Women) Are you pregnant?
Check if you have ever had any of the following:

Authorization

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.



Security Measure