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Connolly Orthodontics Authorization for Release of Information Friends & Family Name of Patient Date of Birth Connolly Orthodontics is authorized to release protected health information about the
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To fill out Connolly Orthodontics, follow these steps:
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Begin by filling in your personal information, including your full name, date of birth, and contact details.
03
Provide your dental insurance information if applicable, including the insurance company's name and your policy number.
04
Indicate the reason for your visit or treatment, such as braces consultation, orthodontic treatment, or other oral issues.
05
Answer any medical history questions, including allergies, current medications, and any past surgeries or significant medical conditions.
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Specify your preferred appointment date and time, if applicable.
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Sign and date the form to indicate your consent and agreement to the terms and conditions.
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Submit the completed form to Connolly Orthodontics either in person or through their online submission portal.

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Connolly Orthodontics is for individuals who require orthodontic treatment or consultation for various dental issues, including but not limited to:
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- Crooked or misaligned teeth
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- Overbite, underbite, or crossbite
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- TMJ disorders or jaw misalignment
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- Crowded teeth
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- Open bite
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- Overlapping teeth
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- Dental issues related to facial aesthetics or smile improvement
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- Any other dental or oral concern that requires expert orthodontic care
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Orthodontic treatment can be beneficial for both children and adults. If you have any dental issues mentioned above or are interested in improving your smile, Connolly Orthodontics can help.
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Connolly Orthodontics is a dental practice specialized in orthodontic treatment, such as braces and Invisalign.
Patients who have received orthodontic treatment at Connolly Orthodontics may be required to file their treatment records with their insurance provider or dental benefit plan.
Patients can fill out Connolly Orthodontics forms either in person at the office or online through the practice's patient portal.
The purpose of Connolly Orthodontics is to provide patients with quality orthodontic treatment to help them achieve a straighter and healthier smile.
Information reported on Connolly Orthodontics forms may include patient contact information, medical history, treatment plans, and progress notes.
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