20 YEARS creating timeless smiles!

1248 East 90 North, Suite 201, American Fork, UT 84003
801.763.7977 www.itsorthotime.com

Orthodontic Health History

Jeremy R. Watson DDS, MS 1248 East 90 North, Suite 201, American Fork, UT 84003

Step 1 of 2

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Patient’s Name:
Name they would like to be called:
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Sex:
Patient’s Address:
School:
Grade:
Mother’s Name::
Father’s Name:
Siblings:
Emergency contact name and number:
Parental Marital status:
Who has legal custody of patient?
Dentist:
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Whom may we thank for referring you to us?
What is the reason for today’s visit?

INSURANCE INFORMATION

Person financially responsible for this account:
Insurance coverage for Orthodontic treatment?
Insurance Company:
Address:
Primary Policy Holder Name:
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Secondary Insurance Company:
Address:
Primary Policy Holder Name:
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PATIENT PROFILE

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20 YEARS creating timeless smiles!