_2017 Adult Registration Form – Ortho

Patient Information

Phone Type

Spouse / Partner Information

Dental Insurance Information

Primary Dental Insurance

Secondary Dental 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:


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.

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