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Adult New Patient Form
Title
Gender*
Spouse's Title
Marital Status
INSURANCE INFORMATION
Do you have Dental Insurance?
*
Yes
No
DENTAL BACKGROUND
Have you visited an orthodontist before?
*
Yes
No
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims.
Privacy Notice
I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by my insurance. ​ I have also received a copy of the Notice of Privacy Practices:
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