New Patient Form

We would like to welcome you to our office. In an effort to provide the best service possible, it is required that you fill out this form as completely as possible.

Patient Information

General Information

Responsible Party Information

If you have orthodontic insurance coverage for the patient, please complete:
If you have orthodontic insurance coverage for the patient, please complete:

Medical History

Dental History

I certify that the above information is correct and that this office will not be held responsible for situations arising out of inadequate information of information not disclosed. I authorize Heidi Harman Orthodontics, LLC to share any and all of this patient’s diagnostic records, images, photos, etc. and pertinent information with doctors, dentists, surgeons, and insurance companies or any individual or entity necessary to provide and complete care for this patient. I was offered a copy of this office’s Notice of Privacy Practices/HIPAA disclosure.

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