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baby and rojas orthodontics

  • PATIENT INFORMATION

    For Under 18 Years of Age
  • Welcome to our practice. Please fill out this form as completely as you can. The following is essential for our staff to provide dental care in a manner that is compatible with you/your child’s general health. Your cooperation in providing accurate information is necessary to safely and efficiently protect your dental needs. Incorrect information can be dangerous to your health. If you have any questions, we would be glad to help you.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Age 
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  • Preferred NameGender IdentificationPreferred Pronouns 
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  • SchoolSports/Hobbies 
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  • BILLING PARTY INFORMATION

  • Home PhoneWork PhoneCell Phone/Other Phone 
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  • EmployerOccupation 
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  • Relationship to PatientCell PhoneWork Phone 
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  • EmailEmployerOccupation 
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  • DENTAL HISTORY

  • Date Format: MM slash DD slash YYYY
  • MEDICAL HISTORY

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  • Please check Yes or No (If yes, please fill in details)
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  • Height of biological parents?
  • MotherFather 
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  • BENEFITS

  • Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontic is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purpose. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Baby or Dr. Rojas to perform a complete orthodontic evaluation.
  • Signature:Date: 
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