20 YEARS creating timeless smiles!

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

Adults

Orthodontic Health History Adults

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

Step 1 of 2

MM slash DD slash YYYY
Patient’s Name:
Name you would like to be called:
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Please circle one:
Patient’s Address:
Untitled
Emergency contact name and number:
Employer
Spouse his or her name:
Employer
Are family members seen by us?
Whom may we thank for referring you to us?
What is the reason for today’s visit?
Dentist:
MM slash DD slash YYYY

INSURANCE INFORMATION

Person financially responsible for this account:
Insurance coverage for Orthodontic treatment?
Insurance Company:
Address:
Primary Policy Holder Name:
MM slash DD slash YYYY
Secondary Insurance Company:
Address:
Primary Policy Holder Name:
MM slash DD slash YYYY

PATIENT PROFILE

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20 YEARS creating timeless smiles!