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Patient Information

FIRST NAME:LAST NAME:MIDDLE NAME:COMMON NAME:BIRTHDAY:STREET ADDRESS:CITY:ZIP CODE:EMAIL:PHONE:GENERAL DENTIST:REFERRAL SOURCE:NAMES OF FAMILY MEMBERS SEEN IN OUR OFFICE:IF A MINOR, DOES PATIENT LIVE WITH:

RESPONSIBLE PARTY INFORMATION

PLEASE CHOOSE RELATIONSHIPFIRST NAME:LAST NAME:COMMON NAME:OCCUPATION:BIRTHDAY:SS#:HOME PHONE:WORK PHONE:CELL PHONE:DO YOU HAVE DENTAL INSURANCE?YESNOINSURANCE NAME:PLEASE CHOOSE INSURED RELATIONSHIP TO PATIENT:FIRST NAME:LAST NAME:MIDDLE NAME:EMPLOYER:OCCUPATION:BIRTHDAY:SS#:HOME PHONE:WORK PHONE:CELL PHONE:DO YOU CONSENT ORTHODONTIC EVALUATION/TREATMENT FROM RISINGER ORTHODONTICS?YESPLEASE TYPE YOUR NAME AS A DIGITAL SIGNATURE TO CONFIRM YOUR CONSENT FOR ORTHODONTIC EVALUATION/TREATMENT:DATE:

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MEDICAL INFORMATION

ANY KNOWN DRUG ALLERGIES? If none please enter "NONE"MEDICATIONS PATIENT IS CURRENTLY TAKING. If none please enter "NONE"

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