Adult Patient:

Please fill out the form and submit. Do NOT print and bring the form into the office.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Our office uses an Automated System for confirming all appointments. This system gives the option for calling and texts.
 
Best telephone number to use?
 
 
 
 
 

Spouse Information

 
 
 
 
 
 
 
 

Medical History

 
 
 

Please Check the following As They Apply:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please explain any other health problems and list all medications currently taking (including non-prescription drugs)
By signing below, I acknowledge receipt of a copy of the Notice of Privacy Practices of Innovative Orthodontics, Donihue Waters, DDS, MDS.
 
 
 

Insurance Information:

Primary

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Upload Insurance Card
 
 

Secondary

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Upload Insurance Card
 
 
Our office files insurance as a courtesy for our patients. We cannot file your insurance without a copy of your insurance card. If you do not have a copy of your card, please contact your Human Resources Department.