CONTACT US

We'd love to hear from you!

We care about our patients. At Risinger Orthodontics we treat you with respect and courtesy at all times. It is our goal to provide you with the best customer service possible. Give us a call or fill out the form below and we’ll get back to you promptly.

Our Info

Email:

ortho1@ktc.com

phone:

830-257-8922

Main office address

715 Hill Country Dr. Suite #3
Kerrville, TX 78028

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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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