Ortho New Patient Form

Patient Information

Emergency Contact Information

Dental Insurance Information

If you are covered by more than one dental insurance plan, please be aware there are industry guidelines that determine which plan is considered primary and which is secondary. Insurance claims must be sent to your primary insurance company prior to submitting a claim to your secondary insurance plan.
 

For the printed form, please click on the button below.

Click below for a copy of our Office Policies.