Information Verification
Please assist us by completing the form below :)
Patient Name:
*
First Name
Last Name
Preferred Name:
Gender:
*
Please Select
Male
Female
Birthdate:
*
-
Month
-
Day
Year
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Verify/Update Phone Number:
*
Your health history form will be texted to this address.
Format: (000) 000-0000.
Verify/Update Email Address:
*
Your health history form will be emailed to this address.
Verify/Update Mailing Address:
*
Street Address
Additional Address Line
City
State / Province
Postal / Zip Code
Are there any new concerns regarding your teeth?
*
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Responsible Party Information
The Responsible Party is the person who will be financially responsible for orthodontic treatment and must be at least 18 years of age.
Is the Patient the same person as the Responsible Party?
*
Yes
No
Responsible Party Name:
*
First Name
Last Name
Verify/Update Phone Number:
*
Format: (000) 000-0000.
Verify/Update Email Address:
*
Relationship to Patient:
*
Please Select
Self
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Spouse
Other
Verify/Update Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Dentist Information
Does the Patient have a dentist that they see regularly?
*
Yes
No
What is the name of the dentist or dental practice?
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Dental Insurance
Please provide as much information as possible to help us accurately determine any insurance benefit you may have.
Does the Patient Have Dental Insurance?
*
Yes, and I will provide this information now.
Yes, but I have already provided this information to your office.
No
Select one:
Take photos of the insurance card (front and back)
Manually enter the information
Photo of Insurance Card (FRONT)
Photo of Insurance Card (BACK)
This Dental Insurance is which of the following:
Employer Sponsored Dental Insurance
Private Dental Insurance
Medicaid
None of these
Employer
Insurance Company
Subscriber / Policy Holder's Name
First Name
Last Name
Subscriber / Policy Holder's Birthdate
*
-
Month
-
Day
Year
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Please provide one of these so that we may locate your policy:
*
Subscriber ID / Member ID
Social Security Number
Subscriber ID / Member ID
Social Security Number
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Secondary Dental Insurance
Please provide as much information as possible to help us accurately determine any insurance benefit you may have.
Does the Patient have Secondary Dental Insurance?
*
Yes, and I will provide this information now.
Yes, but I have already provided this information to your office.
No
Select one:
Take photos of the insurance card (front and back)
Manually enter the information
Photo of Insurance Card (FRONT)
Photo of Insurance Card (BACK)
This Secondary Dental Insurance is which of the following:
Employer Sponsored Dental Insurance
Private Dental Insurance
Medicaid
None of these
Employer
Insurance Company
Subscriber / Policy Holder's Name
First Name
Last Name
Subscriber / Policy Holder's Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
Please provide one of these so that we may locate your policy:
Subscriber ID / Member ID
Social Security Number
I will provide this information at a later date.
Subscriber ID / Member ID
Social Security Number
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Please verify that you are human
*
Reply-to Email:
example@example.com
Please include any other information below that you would like us to know:
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