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Confidential Patient Information
Welcome to Phillips Family Orthodontics! Please complete this *HIPAA compliant* form. We look forward to serving you.
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Patient First and Last Name
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Your answer
Patient Birthday
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DD
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Patient Sex at Birth, and Preferred Pronouns if Desired
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Responsible Party Name, and Relationship to Patient
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Contact Phone Number
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Contact Street Address, City, State
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Reason for visit - how can we help you?
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How did you hear about our office?
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Do you have an insurance plan you would like us to reference?
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