Patient Information Form

Please correct the errors described below.

Patient Information

Minor Patient's Siblings and Ages

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Financially Responsible Information

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Emergency Contact Information (Someone NOT at above addresses)

I GIVE PERMISSION TO DISCLOSE PROTECTED HEALTH INFORMATION TO THE FOLLOWING PERSONS:

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Medical History

Has patient ever been diagnosed or treated for:

Dental History

If the patient will be in orthodontic therapy, We require a general dental visit every six months.

What's Important?

Dental Insurance Claim Information

    Please upload a file

    I promise all information given is accurate and true. I authorize release of any information relating to this claim and necessary for processing. I authorize payment directly to Henn Orthodontics of the insurance benefits otherwise payable to me.

    By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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