Jacobus Orthodontics Adult Health History Form Logo

  • Jacobus Orthodontics Adult Health History Form

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  • Spouse Information

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  • Orthodontic Insurance

    Primary
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  • Orthodontic Insurance

    Secondary
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  • Emergency Contact

  • Medical History

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  • Dental History

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  • Office Use Only

  • I verbally reviewed the medical/dental information with the parent/guardian and the patient named herein.

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  • Acknowledgement of Privacy Practices

  • THE UNDERSIGNED ACKNOWLEDGES THE CURRENTLY EFFECTIVE NOTICE OF PRIVACY PRACTICES FOR DR. BRIAN B. JACOBUS, JR, D.D.S.,M.S.,P.A.

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  • A COPY OF THIS SIGNED, DATED ACKNOWLEDGMENT SHALL BE EFFECTIVE AS THE ORIGINAL

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  • IF YOU ARE THE LEGAL REPRESENTATIVE OF THE PATIENT, PLEASE PRINT YOUR NAME IN DESCRIBED AUTHORITY

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