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    GUARDIAN #1 / INSURANCE INFORMATION















    INSURANCE (IF APPLICABLE):




    GUARDIAN #2 / INSURANCE INFORMATION

    SLEEP / AIRWAY ISSUES

    DENTAL/MEDICAL HISTORY

    Please check if the patient has, or ever had, any of the following habits?

    SIGNED CONSENT

    I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

    I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

    I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.





    By submitting this form you agree to the above mentioned consent statement

    Our Patients Say

    This place is great! State of the art equipment. Friendly staff and they have cookies! ?? Fresh ones!

    Vanessa P

    I have finally found a dentist/hygienist that I feel comfortable with. I was there today and felt relaxed the entire time and am actually looking forward to going back for more dental work. Weird, but true.

    Carol S

    I came in and I felt so welcomed with the lady I met up front. The assistant and hygienist was so amazing and made me feel so comfortable. And then the dr he was awesome I will definitely make this my new home!

    Anonymous

    The staff here is always happy to help me with my questions and concerns.

    Evan C.

    Wow what a great place: treated like a queen Staff are friendly and genuine care about my health.

    Noreen S.

    What a warm and professional office. It really shows that they care a great deal for their patients. Dr.McCulla is wonderful and has an amazing chairside manner.

    Charlene T

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