Registration Information
Gender
Birthdate
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Address of Patient
Has the patient ever been in this office before?
Has any other member of your family had orthodontic care at this office?
Did he/she refer you to our office?

Is the patient a minor?
Parent/Guardian #1
Birthdate
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Add 2nd Parent/Guardian
Parent/Guardian #2
Birthdate
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Medical History
Does the patient have or has he/she ever had:
ADHD
Diabetes
Pacemaker
Abnormal Blood Pressure
Epilepsy
Prolonged Bleeding
Anemia
Frequent Headaches
Radiation Therapy
Arthritis
HIV+/AIDS
Rheumatic Fever
Asthma or Breathing Problem
Heart Disease
Sinus Trouble/Hay Fever
Autism
Heart Murmur
Stroke
Autoimmune Disorder
Hepatitis or Liver Problems
Tuberculosis or Lung Disease
Cancer or Leukemia
Herpes/Venereal Disease
Ulcers
Congenital Heart Defect
Osteoporosis

Does the patient have or has he/she ever had Allergies to:
Latex
Local Anesthetic
Allergy to Other Medication

Other Allergies

Pregnant (if yes, due date)?
Due Date
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Dental Insurance Information
Do you have dental insurance that may cover any part of orthodontic services?
Insured (Employee) Date of Birth
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Effective Date
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If more than one dental insurance, is this one:
Do you have additional dental insurance?
Dental Insured (Employee) Date of Birth
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Effective Date
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Consent Signatures
By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health. I authorize the dental staff to perform necessary dental services that I, or my child, may need during diagnosis and treatment.
Date
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I authorize my doctor and his / her designated staff, to perform an examination, for the purpose of diagnosis and treatment planning. If medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions regarding this Notice.
Accept or Decline
Date
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I permit messages to be left on my phone and/or mobile phone(s) concerning appointments, treatment, insurance, and my account.
Accept or Decline
Date
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