Online Health History Form

Patient Information

Date*

Date of Birth (MM-DD-YYYY)*

First Name*

Middle Name

Social Security Number (Over 18)

Last Name*

Cell/Other Phone*

Nickname

Cell Phone Carrier*

Address*

Street Address City State ZIP Code

Employer (Over 18)

Occupation (Over 18)

School Attending

Email Address*

Responsible Party

If the patient is a minor or a dependent adult, please fill out the responsible party section.

First Name

Mother's Name

Last Name

Mother's Cell Phone Number

Date of Birth (MM-DD-YYYY)

Mother's Cell Phone Carrier

Relationship to Patient

Father's Name

Social Security Number

Father's Cell Phone Number

Who does the child reside with?

Father's Cell Phone Carrier

Other's Name

Other's Cell Phone Number

Other's Cell Phone Carrier

Address

Street Address City State ZIP Code

Dental Insurance Information

Primary Carrier

Insurance Company

Policy Holder's Name

Policy Holder's Social Security Number

Policy Holder's Date of Birth (MM-DD-YYYY)

Policy Holder's ID

Policy Holder's Group Number

Insurance Company's Phone Number

Relationship to Patient

Secondary Carrier

Insurance Company

Policy Holder's Name

Policy Holder's Social Security Number

Policy Holder's Date of Birth (MM-DD-YYYY)

Policy Holder's ID

Policy Holder's Group Number

Insurance Company's Phone Number

Relationship to Patient

Getting to Know You

Is another member of your family or relative a patient at our office?*

Yes

No

What is their name?

Relationship

Who may we thank for referring you?*

Reason for wanting an orthodontic consultation*

HIPAA Privacy Policy

I allow any records and/or information to be disclosed or released to the following:*

Another dental professional

Another medical professional

Other (family, friends, guardian, step-parents, grandparent, babysitters...)

Please list:*

We ask that you read our Notice of Privacy Practices before your first appointment. Click the link below to review.
https://www.csorthodontics.com/patient-forms

I have read the Notice of Privacy Practices*

Yes

No

Enter your name here as a digital signature confirming the previous statement.*

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Patient

Experience

Our Orthodontists Are Dedicated to
Providing the Best Patient Experience.

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Request a Complimentary Exam Today!

What our patients are

Follow Us

Don't Wait

Request a Complimentary Exam Today!

What our patients are

Follow Us

Patient

Experience

Our Orthodontists Are Dedicated to Providing the Best Patient Experience.

Don't Wait

Request a Complimentary Exam Today!

What our patients are

Follow Us

Instagram

facebook

Tiktok

Don't Wait

Request a Complimentary Exam Today!

What our patients are

Follow Us

Instagram

facebook

Tiktok

Our Orthodontists Are Dedicated to
Providing the Best Patient Experience.