• Health History Form

    Save time by filling out your health history form online before your first appointment. Take a few minutes to fill out this form, click submit at the bottom, and your information will be sent to us with secure encryption.
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  • RESPONSIBLE PARTY INFORMATION

    Billing contact information
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  • Dental Insurance Information

    We are happy to check on your orthodontic benefits for you. If you have dental insurance, please provide us with the following information. When you arrive for your first appointment, we will go over your orthodontic coverage with you.
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  • Emergency Contact Information

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  • Medical History

    Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
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  • Dental History

  • Acknowledgement of Privacy Practices

    Click the link below to view our privacy practices.
  • Photo Release Consent

    We are proud of the beautiful smiles we create here at Peachtree City Orthodontics. If you select "yes" below, you are giving us consent to use your/your child's photograph in our office for internal use (pictures the wall, brochures, contests, etc), website and social media. It is understood that any permission granted at this time may be revoked by contacting our office.
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