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New Patient Form
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  • 3
    Cell Phone # of person responsible
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  • 4
    Only for text appointment reminders if your child drives themselves 
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    Please Select
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  • 10
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  • 11
    Someone? Google? Facebook? Walk-by? Other? Car Ad?
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  • 12
    Scroll down for more options
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  • 13
    Scroll down for more options
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  • 14
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  • 15
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  • 16
    Please list medications below. Skip if none.
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  • 17
    (or legal guardian. Type "none" in each field if no mother)
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  • 18
    (or legal guardian. Type "none" in each field if no father)
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  • 19
    Scroll down for more options
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  • 20
    Scroll down for more options
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  • 21
    Cigarettes, cigars, chewing tobacco etc.
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  • 22
    Cigarettes, cigars, chewing tobacco etc.
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  • 23
    Scroll down for more options
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  • 24
    Scroll down for more options
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  • 25
    Type "none" if you don't have one
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  • 26
    Type "none" if you don't have one
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  • 27
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  • 28
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  • 29
    For your convenience take a photo of the FRONT of your insurance card (Optional):
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  • 30
    Take photo of the BACK of your insurance card (Optional):
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  • 31
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  • 32
    We can estimate your coverage if you provide the following information about your insurance company:
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  • 33
    We can estimate your coverage if you provide the following information about your insurance company:
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  • 34
    We can estimate your coverage if you provide the following information about the Policyholder:
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  • 35
    In an urgent situation, is there someone who lives near you that we should contact?
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  • 36
    What would you like Dr Leo to address?
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  • 37
    Please click on the link below to read how we protect your private information. Haga clic en el enlace a continuación para leer cómo protegemos su información privada.
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  • 38
    Name of person filling this form out
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  • 39
    The information, health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental/orthodontic services including x-rays agreed between doctor and patient to be necessary or advisable. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered (i.e. I understand that if my insurance stopped paying, I will be responsible to pay what the insurance was supposed to pay for). If I ever have any changes in my health or if my medication changes I will, without fail, inform the doctor at my next appointment.
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  • 40
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  • 41
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