Adult Patient Information

Responsible Party Information

INSURANCE INFORMATION



Whom may we notify (other than above listed parties) in case of an emergency?

Signature on file
I understand that I am responsible for all costs of dental treatment.
I authorize the use of this form and its information for all my insurance submissions.
I authorize this office and its employees to act as my agent in helping me obtain reimbursement.
I authorize insurance payment directly to this office.
I authorize use of a copy of this form which can be used in place of the original.

For the following questions select yes, no, or don't know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Medical History (Now or in the past, have you had)

Dental History
I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status I will so inform this practice.
Security Captcha