• Adult Patient Health History Form

  • About You

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  • Address

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  • Medical Health Information

  • Dental Insurance Information

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  • Dental Health Information

  • How often to you brush and floss?

  • Photo Release

  • I acknowledge that the above information is correct. I will notify Dr. Jewett of any changes that occur after this date. I hereby authorize Dr. Jewett and his team to perform an initial orthodontic evaluation/examination. 

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