Patient Information Form
Patient Name
Birthdate
Social Security #
Cell Phone
Email Address
If patient is minor, give parent or guardian's name
Responsible Party Information
Name
Marital Status
Single
Married
Divorced
Widow
Home/Cell Phone
Work Phone
Email
Birthdate
Relationship To Patient
Insurance Information
Insured's Name
Birthdate
Insured's Social Security #
Insurance Co. Name
Phone #
ID #
Group #
Upload Front Side of Insurance Card
Upload Back Side of Insurance Card
Health History
Dentist Name
Date of Last Visit to the Dentist
Main Concern
List Any Dental/Jaw Pain or Discomfort
List Any Medical Conditions that would interfere with Orthodontic Treatment
Signature (Parent's signature, if minor)
Date