Adult Intake

Adult Intake
Welcome to the orthodontist
1. About You
Today's date

Month Day Year
Your name *

First Name MI Last Name
E-mail
Birthdate *

Month Day Year
Gender *

Male Female
How old are you? *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Whom we may thank for referring you? *
General Dentist *
Last visit date
Marital status

Single Married Partnered Separated Divorced Widowed

2. Spouse Information
Name

First Name Last Name
Other family members seen by us

3. Primary orthodontic insurance
Orthodontic coverage *

Yes No
Insurance company name *
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company Phone Number

Area Code Phone Number
Group #
Policy #
Policy owner's Name

First Name Last Name
Relationship to the patient
Policy owner birthdate

Month Day Year
Policy owner's employer
Employer's address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Orthodontic Insurance
Orthodontic coverage

Yes No
Insurance company name
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company Phone Number

Area Code Phone Number
Group #
Policy #
Policy owner's Name

First Name Last Name
Relationship to the patient
Policy owner birthdate

Month Day Year
Policy owner's employer
Employer's address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

7. 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 medical status

I am 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.
I authorize the dental staff to perform the necessary dental services I may need. *

Clear
This office reserves the right to verify the credit status of potential patients' prior to extending credit for treatment fee and may, at discretion of this office, use the services of one or more credit reporting services. *

Clear
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic. *

Clear
Date

Month Day Year
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