• New Patient Registration

  • Date of Birth Patient?*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date of Birth for Parent/Guardian*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth for Parent/Guardian
     . .
    2 digit month, 2 digit day, 4 digit year
  • Do you have Dental Insurance*
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  • Date of Birth of Subscriber:*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Do you have Secondary Dental Insurance*
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  • Date of Birth of Subscriber:*
     . .
    2 digit month, 2 digit day, 4 digit year

  • Medical History:

  • Do you have any of following?*
  • Do you have any of the following allergies?*

  • Dental History

  • Date of last dental cleaning?*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Do you or have you in the past had any of the following habits?*
  • Are you currently experiencing any of the following?*
  • Do you have or have you ever had any of the following?*
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  • Patient Disclosure and Acknowledgements

  • Panoramic Radiographs and Records Fee

    As part of your initial consultation, Fallsgrove Orthodontics will do a thorough evaluation of your soft and hard tissues, developing permanent teeth, and overall dental health. It may be required for Fallsgrove Orthodontics to take photographic images of your teeth and a panoramic x-ray.

    If you, your general dentist, or any dental specialist request a duplication of any and/or all records taken during your consultation, and you have not started treatment in our clinic and are not a patient of record, there may be a fee of $100.00 assessed.

    By signing below, you are agreeing to have the necessary images taken and to pay the $100.00 fee if required.

  • Patient Records of Disclosure

    We may need to discuss the patient's treatment plan and/or share records with your general dentist or any dental specialist. 

    By signing below you give Fallsgrove Orthodontics permission to share any and all necessary in records/information with your provided general dentist and/or dental specialist.

     

  • I confirm that the information I provided on this health form is true to the best of my knowledge. I understand it's my job to tell Fallsgrove Orthodontics if anything changes with my health or personal info.

    By signing below, I agree to the collection, use, and sharing of my personal and health information as described in the Privacy Policy. See attachment. I understand that this information will be used for treatment, payment, and healthcare operations.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: