Online Patient Health History Form

    Online Patient Health History Form

    Submit Your Health History Form Online to Your Orthodontist

    Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.

    This website is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All of your personal health information is confidential, and will not be shared with anyone, aside from those involved in your treatment, without your consent.

    Patient Information
    Items marked with asterisk (*) must be completed.
    Gender*
    MaleFemale
    Address*
    Responsible Party Information
    Gender
    MaleFemale
    Check if contact information is the same:
    Address
    Dental Insurance Information
    Employer Address
    Insurance Address

    Medical History

    CONFIDENTIAL Now or in the past, has the Patient had:
    Allergies or Reactions to any of the following?
    For Women only:
    Please check the box if you are pregnant

    Dental History

    I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
    By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
     
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