Confidential Adult Patient Health History and Information for Sher Smiles Orthodontics
Please allow 15-20 minutes to complete this form in its entirety. Thank you!
Today's Date *
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We are excited to have you in our office! Whom may we thank for referring you?
Confidential Patient Information
Name *
Gender *
Marital Status
Clear selection
Residence Address: Street *
Residence Address: City *
Residence Address: Zip Code
Home Status
Clear selection
Billing Address (If different than residence)
How long have you lived at this address?
Cell Phone:
Work Phone:
Email address:
Which would you prefer for appointment reminders?
Clear selection
Social Security No.
Birth date: *
MM
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DD
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YYYY
Employer:
Occupation:
Number of years employed:
Spouse Information (If applicable)
Spouse's Name
Spouse's Cell Phone:
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