New Patient Health History Form
We would like to welcome you and your family to Mack and Hansen Orthodontics. In an effort to provide the best service possible we offer you the ability to complete the new patient paperwork online from your computer or phone. We ask you to fill out this form as completely as possible. Thank you so much and we look forward to seeing you soon!
Patient information
Patient’s First Name *
Your answer
Patient’s Last Name *
Your answer
Preferred Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender *
Best Phone # *
Your answer
Contact Email: *
Your answer
Cell Phone Carrier (Allows us to send appointment reminders through text) *
Your answer
How do you prefer to receive appointment reminders? *
Required
Relatives treated at our office
Your answer
How did you hear about our office? *
If you heard about us from a friend, who was it?
Your answer
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