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  • Adolescent Intake

  • Welcome to the orthodontist

  • 1. Tell us about your child

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  • 2. Who is accompanying your child today?


  • 3. Parents

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  • 4. Person responsible for account

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  • 5. Primary orthodontic insurance

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  • Secondary Orthodontic Insurance

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  • 7. Has your child ever had any of the following medical problem?

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  • 8. Has your child ever experienced any of the following?

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  • 9. I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office any changes in my child's medical status

    The parent or guardian who accompanies the child is responsible for payment. Our office is HIPAA compliant and is committed to meeting or exceeding the standards infection control mandated by OSHA, the CDC, and the ADA.
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