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