Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Mailing Address:
City:
State:
Zip:
Physical Address:
City:
State:
Zip:
How long at this address?
Home Phone:
Email:

Family Dentist:
Last Visit Date:
Primary Care Physician:

Whom can we thank for your referral?
Other family members seen?

Responsible Party Information

Are you planning on using a Health Savings or Flex Spending Account for orthodontics treatment?
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Marital Status:
Relationship to Patient:
Social Security Number:
Main Phone:
Cell Phone:
Employer:
Length of Employment:
Work Phone:

Other Spouse or Partner's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Marital Status:
Relationship to Patient:
Social Security Number:
Main Phone:
Cell Phone:
Employer:
Length of Employment:
Work Phone:

Dental Insurance Information

Do you have orthodontic insurance?
(If yes, complete information below)
Insurance Company Name:
Policy Holder's Name:
Group Number:
Policy Holder's ID or Social Security Number:
Policy Holder's Birthdate:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone: