We never want costs to stand in the way of quality treatment, which is why we are dedicated to providing our patients with care that is both effective and affordable. Your treatment plan will include a breakdown of all applicable fees, and we will inform you of all costs before treatment is administered.We offer a variety of payment options to meet your needs. Our office accepts payments by cash, checks, and Visa, MasterCard, American Express and Discover credit cards. If full payment is made at the onset of treatment, we offer a fee discount. We also offer a discount to siblings receiving treatment.

Affordable Financing Options
Don’t let finances stand in your way for achieving the beautiful, healthy smile you deserve! We are pleased to offer in-house financing to help make your treatment more affordable. This is a flexible payment option that allows you to pay for your treatment over a period of time so you can focus on what matters most – keeping your smile healthy!

If you have any questions about financing or payment, ask us! We will thoroughly explain your choices and work hard to accommodate you.

Insurance

Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts.

When you first visit our office, bring your current insurance card with you. If you change insurance companies or join another employer’s plan, please be sure to let us know. If an insurance referral is necessary, please bring the completed form with you to your appointment.

Please note: Although we file all insurances, we do not accept Medicaid or CHIP insurance plans.

We will fully attempt to help you receive full insurance benefits; however, you are personally responsible for your account, and we encourage you to contact us if your policy has not paid within a reasonable timeframe. If we are not contracted under your insurance, you will be given a copy of services and charges to file with your insurance claim form.

Please fill out the form below.

Patient Information

Patient Name: *

Gender:

Male
Female

Social Security Number:

Birth Date: *

Age:

Home Address: *

City: *

State: *

Zip: *

Primary Phone Number: *

Type:
Home
Cell

Email Address: *

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages)

Parent/Guardian Information

Parent Marital Status:

Guardian 1

Relationship

Name *

Social Security Number

Birth Date *

Driver's License Number

Address (if different than child's) *

City *

State *

Zip *

Primary Phone Number *

Type
Home
Cell

Secondary Phone Number

Type
Home
Cell

Employer

Occupation

Guardian 2

Relationship

Name *

Social Security Number

Birth Date *

Driver's License Number

Address (if different than child's) *

City *

State *

Zip *

Primary Phone Number *

Type
Home
Cell

Secondary Phone Number

Type
Home
Cell

Employer

Occupation

Emergency Contact

Emergency Contact Name (other than parent)

Phone Number

Relation to child

Address

City

State

Zip

Person(s) OK to release appointment or medically related information to concerning child

Relation

Insurance Information

Primary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

Dental History

General Dentist

Last Visit

How did you hear about our practice?

Name of person referring (if applicable)

What are the main concerns you would like orthodontics to accomplish?

Has your child visited an orthodontist before?

Yes
No

When?

Reason?

Has your child's tonsils or adenoids been removed?

Yes
No

Has your child ever experienced jaw joint pain/discomfort?

Yes
No

Does your child have any missing or extra permanent teeth?

Yes No

Has your child ever had an injury to (select all that apply)

Teeth
Mouth
Chin

Does your child have speech problems?

Yes
No

If so, explain:

Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?

Yes
No

Reason

Physician

Last Visit

Phone

Does your child have any allergies/sensitivities to medications or latex?

Yes
No

If yes, please list allergies:

Is your child currently taking any prescription or over-the-counter medications?

Yes
No

Please list, with dosage:

Has puberty and/or menstruation begun?

Yes
No
N/A

Has your child ever taken any of the group of drugs collectively referred to as 'fen-phen?' These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes
No

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?

Yes
No

If yes, give approximate dates:

Is your child pregnant?

Yes
No

Nursing?

Yes
No

Taking birth control pills?

Yes
No

Check if your child has or have ever had any of the following:

Authorization

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.

Patient Signature and/or Responsible Party *

Date *

LONGVIEW OFFICE

903-757-0534
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ATLANTA OFFICE

903-796-6250
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GILMER OFFICE

903-757-0534
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430-625-3873
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