Redwood Shores Orthodontics Patient Registration Form

Please fill out this form as completely as possible. The information provided is confidential and will only be used in our office records.

   

General Patient Information

Medical and Dental History

Craniofacial Syndromes

Responsible Party Information

Dental Insurance Information

- Please complete this section if you would like us to check the orthodontic benefit on the dental insurance
- If the patient does not have any dental insurance, skip this section
- If the patient is covered under one dental insurance plan, fill out the primary dental insurance section only
- If the patient is covered under two dental insurance plans, please fill out both dental insurance sections
- If the patient is covered under more than two dental insurance plans, please print an extra insurance information page

Primary Dental Insurance

Secondary Dental Insurance (if applicable)