New Patient Enrollment Form

New Patient Registration

Please fill in the form below
Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Legal Gender*
Preferred pronoun(s) (OPTIONAL)
Parent/Guardian Name*

First NameLast Name
Relation to patient*
E-mail *REQUIRED FOR APPOINTMENT REMINDERS*
Contact Number:*

Area CodePhone Number
Type of phone: *
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF DENTIST/CLINIC:*
MY LAST CLEANING WAS:*
HAVE YOU/PATIENT HAD AN ORTHODONTIC CONSULT WITH ANOTHER OFFICE? *
WHERE?*
WHEN?*
DOES YOUR CHILD HAVE OHP?*
DENTAL CARE ORGANIZATION (DCO)?*
MEDICAID ID # (8 characters - combination of letters/numbers)*
DO YOU HAVE PRIVATE ORTHODONTIC INSURANCE?*
NAME OF INSURED:*
DATE OF BIRTH OF INSURED:*

MonthDayYear
Date
Name of Insurance Company/Carrier*
ID #*
GROUP #*
EMPLOYER:*
UPLOAD A PICTURE OF YOUR CARD

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