Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Address:
City:
State:
Zip:
Main Phone:
Email:
Gender:
Birthdate:
Employer:
Occupation:
Other Family Members Seen by us:
Dentist:
Date of last Cleaning:
Previous Orthodontic Exam?
Chief Complaint?

Person Responsible for Account

First Name:
Middle Initial:
Last Name:
Relation:
Address:
City:
State:
Zip:
Main Phone:
Work Phone:
Drivers License:
Social Security #:

Insurance Information

Insurance Company Name:
Subscriber ID:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Company Phone:
Group Number:
Policy Holder's Name:
Do you have dual dental coverage?
(If yes, complete information below)
Insurance Company Name:
Subscriber ID:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Company Phone:
Group Number:
Policy Holder's Name:

I authorize the office, to perform necessary dental services that I may need at this appointment, including dental x-rays.
Signature:
*By typing my name above I am electronically signing this form.