Patient Registration | Cypress, TX | True Image Orthodontics

Are you currently being treated by a physician?
- Yes
- No
Physician
Last Visit
Phone
Reason
Do you have any allergies/sensitivities to medications or latex?
- Yes
- No
If yes, please list allergies.
Are you currently taking any prescription or over-the-counter medications?
- Yes
- No
Please list, with dosage.
pregnant or nursing?
- Yes
- No
- N/A
- I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.
- I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
- I understand that where appropriate, credit bureau reports may be obtained.
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Ortho Adult Patient Registration Form