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Adult New Patient Information
This form is created using Google Forms and is HIPAA-compliant and encrypted for your security. All information supplied can only be seen by approved CCO Team members. Your information is treated with the highest priority and will not be supplied or sold to any other entity. Please answer all questions so that we might fully understand your concerns.
Email address
First Name
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Last Name
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Date of Birth
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Gender
Preferred Email Address
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Home Address (Street)
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Home Address (City)
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Home Address (State)
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Home Address (ZIP)
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Home Phone
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Cell Phone
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Preferred Method of Contact
Your Dentist's Name
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When was your last visit to your dentist?
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Who may we thank for referring you?
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Has anyone else in your family been treated by our team?
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What is your chief concern or reason for your visit to our practice?
Your answer
How do you feel about wearing braces?
How do you feel about wear removable aligners (Invisalign, etc.)?
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