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Invisible Orthodontics

 Please Read This form was designed for anyone who hates to fill out all those forms at a doctors office when going for an initial visit.  Although you will need to fill out a medical history questionnaire at your first visit to our office, submitting this form beforehand will save you considerable time.  Upon receiving this form, we will transfer the information to our regular paper form, and have you complete and sign it upon your arrival. Although we will need all the information requested on this form, you need only fill in the fields you desire for now.  Information not submitted on this form will be requested of you in person upon arrival at our office. This form is intended as a convenience for our on-line new patients.  There is no requirement to submit this form.  You may simply elect to fill out our forms at your first visit if you prefer. So, then, let's start "getting to know you".

You may also open, print and then complete the entire form by clicking the following link:   Health History.

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Dental Information Prescription Select the topics you want more information on and call us at 307-265-3595 with your email address and request.

American Dental Association Information

Link To Our Electronic Newsletter

 

 
New patient information

 

About You

Gender

I prefer to be called      

Birthdate      Age       Social Security #

Street Address

City        State        Zip 

Marital Status 

Home Phone         Pager        

Cell Phone         Other      

E-mail Address 

Work Phone        Extension 

D.L. Number 

Employer 

Employer's Address 

How long there?        Occupation  

Whom may we thank for referring you? 

Other family members seen by us 

Previous/Present Dentist 

Last Visit Date

Spouse Information
Spouses Name 
Spouse's Employer 
Spouse's Work Phone            Extension      
Social Security #
Birthdate  D.L. Number 

 

 

Responsible Party

Person Responsible for Account 
Work Phone        Extension   
Home Phone       
Billing Address 
Relation       Social Security #
Employer     Drivers License #
Dental Insurance
(Primary)
Insurance Company Name 
Insurance Company Address 
Insurance Company Phone 
Group # (Plan, Local or Policy #)  
Insured's Name   Relation 
Insured's Birthdate        Insured's SS # 
Insured's Employer 
 
 
Dental Insurance
(Secondary)
Insurance Company Name 
Insurance Company Address 
Insurance Company Phone 
Group # (Plan, Local or Policy #)  
Insured's Name   Relation 
Insured's Birthdate        Insured's SS # 
Insured's Employer 
 
In the event of an emergency, is there someone
who lives near you that we should contact?
 
His/Her Name 
Work Phone         Extension 
Home Phone