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  • Adult Intake

  • Welcome to the orthodontist

  • 1. About You

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  • 2. Spouse Information

  • 3. Primary orthodontic insurance

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  • Secondary Orthodontic Insurance

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  • 5. Have you ever had any of the following medical problem?

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  • 6. Have you ever experienced any of the following?

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  • Emergency contact

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  • 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.
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