Patient Health History Form

Please correct the errors described below.

Responsible Party Information

Dental Insurance Information

Emergency Information

Dental History

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

*Female Patients Only*

Patient Motivation for Orthodontic Treatment

Permission to send automated appointment reminder text/emails and to use your/your child's photo on office website, Facebook/ Instagram page and in office

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

Your information will be encrypted.

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