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i smile orthodontics

Patient Information

Sex:
.
What is the patient's nationality? (please check all that apply)

General Information

How Were You Referred To Us?
Have you had any previous orthodontic treatment?
How soon are you looking to start treatment?
Are you interested in a clear bracket/invisible option?

Parent/Guardian/Emergency Contact

Is patient over the age of 18?
Primary Responsible Party:
Is this party financially responsible for patient?
Secondary Responsible Party:
Is this party financially responsible for patient?

Dental Insurance

Do you have dental insurance? Unfortunately, we are not partnered with state insurance carriers at this time (DWP, Hawki, Molina, Amerigroup, etc.)
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If you see value in a payment plan, what is more important to you?

Releases/Waivers

I agree that i smile orthodontic may communicate with me through text messaging and/or email.

I authorize the release of any information regarding the patient's orthodontic treatment to their dental professionals and insurance company.

I authorize my insurance company to make direct payment to i smile orthodontics for procedures billed by the office.

I have read the Notice of Privacy Practice and/or understand I can ask for a copy at any time.

I have answered the above questions accurately and have read the above statements and understand them.

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new patient

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