Adult Patient Forms

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Adult Patient Forms

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

Adult Patient Forms

Patient Information

Name *

Last *

Middle Initial *

Sex *

Marital Status *

Email *

If patient is a student, please provide the parent's email address.

Social Security Number *

D.O.B.

(MM/DD/YEAR)

Street Address *

City *

State

Zip Code

Home Number *

Cell Phone *

Work Phone

If Applicable

Employer *

Occupation *

No. Years Employed *

General Dentist *

Last Visit *

Who may we thank for referring you to our office? *

Additional Contact Information

Insurance Information

Secondary Insurance Information

Agreement

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this office of any changes in my medical status.

I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the office.

I understand that where appropriate, credit bureau reports may be obtained.

Name of person filling out this form *

Today's Date *

Patient Resource Center

Contact Info

8101 Seaton Place, Montgomery, AL 36116

334-272-4900
mail@kingryorthodontics.com

Mon-Thurs: 8:00 am - 5:00 pm
Fri (1st & 3rd of month): 8:00 am - 12:00 pm

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