ADULT PATIENT INFORMATION






 

Home Address

Billing Address (if different from home address)

HEALTH CARE PROFESSIONAL(S)

DENTAL INSURANCE INFORMATION


Policy Holder Date of Birth







If yes, please fill out the following:
 
Secondary Policy Holder Date of birth
 

MEDICAL HISTORY
























DENTAL HISTORY


Photo Release Form

I hereby authorize Shaw Orthodontics or any of their assignees to take photographs, slides, and videos of teeth, jaws and face of myself or child. I understand that the photographs, slides, and videos will be used as a record of care and may be used for communication with other health care professionals, educational publications (orthodontic journals), and educational lectures. The content may also be used for advertising purposes (including website publications, social media posts, etc.

I further understand that if the photographs, slides, and videos are used in any publication or as part of a demonstration, identifying information (first name only) could be used.

I do not expect compensation, financial or otherwise, for the use of these photographs.

A photostatic copy of this policy shall be considered as effective and valid as the original. I have read, understand and agree to the terms set forth in the financial policy as indicated by my signature below. 
 

Photo Refusal Form


I do not authorize Shaw Orthodontics or any of their assignees to use any photographs, slides or videos for advertising purposes (including website publications, social media posts, educational publications and educational lectures.

I understand the photographs, slides and videos will be used only as a record of my care and may be used for communications with other health care professionals.

A photostatic copy of this policy shall be considered as effective and valid as the original. I have read, understand and agree to the terms set forth in the financial policy as indicate by my signature below.
 

Signature

Today's Date