Woodland, CA Family Orthodontist
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Hours: M-F 8:00a - 5:00p
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Why Us?
Why Choose Portalupi
Meet Dr. Portalupi
Meet Your Team
Invisalign®
How Does Invisalign® Work?
Invisalign® for Adults
Invisalign® for Teens
Braces
Different Types of Braces
Braces for Adults
Braces for Teens
Blog
New Patients
What to Expect
Financing & Insurance
Patient Forms
Patient Registration Form
Health Questionnaire
Patient Smile Evaluation
Epworth Sleepiness Scale
HIPAA Consent Form
iCat Informed Consent
Contact
Contact Us
In-Office Appointments
Virtual Consultations
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Patient Registration Form
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Patient Registration Form
Patient Forms
New Patient Registration
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Patient Information
Is the patient a minor?
*
Yes
No
Patient's Name
Gender
Male
Female
Street Address
Apt / Unit / Condo #
City
State
Zipcode
Email Address
Date of Birth
SSN (XXX-XX-XXXX)
Home Phone (incl area code)
Cell Phone (incl area code)
School Name
School City
Grade
Hobbies/Sports
Employer
Occupation
Years Employed
Work Phone (incl area code)
Siblings (current patients or treated elsewhere)
Other Family Members Seen By Us (incl ages)
Dentist's Name
Dentist's Location
Dentist's Phone (incl area code)
Date of Last Visit
Who referred you to our office?
Signature
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Today's Date (mm/dd/yyyy)
Insurance Information
INSURANCE:
If you would like us to accurately determine your orthodontic benefits and subsequently bill your insurance AS A COURTESY for any future treatment, insurance information must be filled out completely BEFORE you come in for your initial appointment. (Note: Orthodontics is Dental and TMJ is Medical)
Do you have orthodontic insurance?
*
Yes
No
Insurance Carrier
Group/Plan Phone (incl area code)
Carrier Address
Group/Plan Number
Name of Primary Insured
Primary Birthdate (mm/dd/yyyy)
Primary SSN
Do you have secondary insurance?
*
Yes
No
Secondary Insurance Carrier
Secondary Group/Plan Phone (incl area code)
Secondary Carrier Address
Secondary Group/Plan Number
Name of Secondary Insured
Secondary Birthdate (mm/dd/yyyy)
Secondary SSN
Responsible Party Information
NOTE:
If separated/divorced the responsible party of the child is the custodial parent. The person responsible for account and signing contract is the only person legally able to acquire any information regarding patient. If responsible party has legal custody of a person under 18 and the relationship to the person is not mother/father, please provide information below.
Name
Relationship to Patient
Employer
Occupation
Years Employed
Work Phone (incl area code)
Home Phone (incl area code)
Cell Phone (incl area code)
SSN (XXX-XX-XXXX)
Date of Birth (mm/dd/yyyy)
Billing Address
Previous Address (if less than 3 years)
Mother's Information
Relationship to Patient:
Mother
Stepmother
Guardian
Name
Date of Birth (mm/dd/yyyy)
SSN (XXX-XX-XXXX)
Home Phone (incl area code)
Cell Phone (incl area code)
Father's Information
Relationship to Patient:
Father
Stepfather
Guardian
Name
Date of Birth (mm/dd/yyyy)
SSN (XXX-XX-XXXX)
Home Phone (incl area code)
Cell Phone (incl area code)
Responsible Party Information
Who is Responsible for Making Appointments?
Name
Relationship to Patient
Home Phone (incl area code)
Cell Phone (incl area code)
If you are NOT the Patient or the Responsible Party filling out this form, please provide:
Name
Relationship to Patient
Address
Home Phone (incl area code)
Cell Phone (incl area code)
Signature
*
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Signature locked. Reset to sign again
Today's Date (mm/dd/yyyy)
*
Emergency Contact Information
Primary Physician’s Name
Physician’s Address
Physician's Phone (incl area code)
Name of nearest relative NOT living with you
Address
Home Phone (incl area code)
Cell Phone (incl area code)
Work Phone (incl area code)
Name
This field is for validation purposes and should be left unchanged.
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