Patient Information

First name

Last name

Date of birth

Phone

These forms are for

MyselfMy spouseMy childSomeone else

How did you hear about us? (optional)

What Brings You In

Primary concern

500 character limit.

Treatment interest (optional)

Clear alignersBracesJust a consultationNot sure yet

Medical History

All fields in this section are optional. Sharing this information helps Dr. Rose prepare for your visit.

Allergies (optional)

Current medications (optional)

Medical conditions (optional)

Previous orthodontic treatment? (optional)

YesNo

Insurance

All insurance fields are optional. You are welcome to complete these at your visit. If you have your insurance card handy, filling this in now lets us verify your benefits before you arrive.

Insurance carrier

Member ID

Group number

Subscriber name (if different from patient)

Subscriber date of birth (if different from patient)

Consents

I have received the HIPAA Notice of Privacy Practices. I understand how Luminary Orthodontics may use and disclose my protected health information. *I consent to orthodontic examination and treatment at Luminary Orthodontics. I understand that treatment plans will be presented and discussed with me before proceeding. *I agree to receive SMS text messages from Luminary Orthodontics at the number provided. Message and data rates may apply. Reply STOP to opt out. (optional)

By clicking submit, you agree to receive SMS text messages from Luminary Orthodontics at the number provided. Message and data rates may apply. Reply STOP to opt out.

Your information is private and secure. Fields marked * are required.

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