• Welcome to Simply Orthodontics!

    We’re so excited to meet you! Please fill this form as accurately as possible. Our office is paperless and we appreciate you doing this from home. This will also help you be seen for your appointment with minimal wait. Thank you.
  • Patient Information

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  • Responsible Party Information

  • Dental Insurance Information

    Providing insurance information prior to your visit will allow us to give you the most accurate quote. We will not bill your insurance until you begin treatment with us. Please leave this section blank only if you do not have dental insurance.
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  • Dental History

    It is important for us to coordinate with your dentist for your orthodontic treatment. We also want you to be up to date with all cleanings and restorative work prior to starting so that we make sure we are only moving healthy teeth.
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  • Let Us See Your Teeth!

    We will need photos of these 5 different angles of your teeth to better diagnose you. Please see the following examples:
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  • I understand that the information I have given on this form is accurate and I am obligated to inform Simply Orthodontics immediately of any future changes. I authorize Simply Orthodontics to provide my health care information to my other health care providers. I authorize release of any information regarding my orthodontic treatment to my dental and/or medal insurance company.

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  • Photo Release Consent: I do hereby relinquish any and all rights to photographs, portraits, transparencies, native prints, polaroids or other photographic reproductions captured with still, motion picture, video, digital or other cameras for use by Simply Orthodontics.

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  • What Is Most Important to You?

    We consider your satisfaction to be of utmost importance and we would like to personalize your orthodontic experience. Although we understand that all of these aspects are valuable, we can better customize your treatment based on your selections.

  • Health History Questionnaire

    Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
  • Do you have any of the following?


  • Females Only

  • Medications

  • Dental

  • I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errorsor omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
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  • Simon Shung, DMD Practice Limited to Orthodontics and Dentofacial Orthopedics 6246 Irvine Blvd Irvine, CA 92620 | p:949.264.3314 f: 888.975.4492 soirvine.com | info@soirvine.com

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