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ADULT ORTHODONTIC ACQUAINTANCE FORM Date Demographic Information Name you would like to be called Age Birth date Social Security Number Sex (Circle one) F M Address Street City Phone Number #1 (Work
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How to fill out orthodontic acquaintance form
How to fill out orthodontic acquaintance form:
01
Begin by providing your personal information such as your name, age, and contact details.
02
Next, fill in your dental history, including any previous orthodontic treatment or ongoing dental issues.
03
Specify your reason for seeking orthodontic treatment and any specific concerns you may have.
04
Indicate any medical conditions or allergies that the orthodontist should be aware of.
05
If you have dental insurance, provide the necessary information for billing purposes.
06
Finally, sign and date the form to indicate your consent and understanding of the provided information.
Who needs orthodontic acquaintance form:
01
Individuals who are considering orthodontic treatment or have been referred to an orthodontist.
02
Patients who have specific dental issues or concerns that they would like to address through orthodontic treatment.
03
People with previous orthodontic experience or ongoing dental problems that may impact their treatment plan.
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What is orthodontic acquaintance form?
Orthodontic acquaintance form is a document used to provide information about a patient's previous orthodontic treatment and outcomes.
Who is required to file orthodontic acquaintance form?
Orthodontists and dentists are required to file orthodontic acquaintance form for their patients.
How to fill out orthodontic acquaintance form?
Orthodontic acquaintance form can be filled out by providing detailed information about the patient's orthodontic history and treatment.
What is the purpose of orthodontic acquaintance form?
The purpose of orthodontic acquaintance form is to ensure continuity of care and provide information about the patient's orthodontic treatment to the treating orthodontist.
What information must be reported on orthodontic acquaintance form?
Information such as previous orthodontic treatment, type of appliances used, duration of treatment, and outcomes must be reported on orthodontic acquaintance form.
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