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baby and rojas orthodontics

  • NEW PATIENT INFORMATION

    Please complete at least 24 hours prior to your appointment. Thank you!
  • Preferred Name
  • Date Format: MM slash DD slash YYYY
  • BILLING PARTY INFORMATION

    Person financially responsible for this patient- if there are two billing parties, form must be completed by both responsible parties,
  • IF THE PATIENT AND BILLING PARTY ARE THE SAME, YOU CAN SKIP TO THE MEDICAL HISTORY
  • MEDICAL HISTORY

  • Please list any medications now being taken by patent (including supplements, herbal and non-prescription. ) Type “none” if applicable.
  • DENTAL HISTORY

  • Date Format: MM slash DD slash YYYY
  • HABITS

  • CONSENT

  • I AUTHORIZE Dr. Baby and Dr. Rojas and/or their staff to perform diagnostic procedures and treatment as may be necessary for proper dentofacial care. I authorize release of any information concerning my (or my child’s) health care for advice and treatment to and from interdisciplinary team members. I understand that where appropriate, credit bureau reports may be obtained. I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment and to the use of the same by the doctor. The information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office on any changes in my medical status. *
  • A copy of this office’s Notice of Privacy Practices has been made available to me below. I understand I may request a copy of my records.

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