Health History Form

Patient Information

Name*

First Last

Sex*

Male

Female

Birthdate*

Age*

Please enter a number from 0 to 115.

(For children) Patient lives with:

Mom

Dad

Both

Marital Status of parents:

Who may we thank for referring you to our office?

Responsible Party Information

Responsible Party Name*

First Middle Last

Relationship to Patient*

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email Address*

Employer

Occupation

Work Phone

Add another responsible party?*

Yes

No

Responsible Party (Other) Information

Name

First Middle Last

Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Email Address

Employer

Occupation

Relationship to Patient

Dental Insurance Information

Subscriber's Name

First Last

Insurance Carrier's Name

Group #

Subscriber's ID #

Subscriber's Date of Birth

Subscriber's Employer

Authorization

I authorize Healdsburg Orthodontics to release any information including diagnosis and the records of any treatment or examination rendered to my child or me during this period of such dental care to third party payors and/or other health practitioners. I give release for the office to use photographs and the first initial or name of my child or self for office bulletin displays and/or office websites. I agree to be responsible for payment of all services rendered on my behalf or my my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

Health History

Online new patient paperwork

Patient Information

Responsible Party Information

Responsible Party (Other) Information

Dental Insurance Information

Patient's Medical History

Authorization

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