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Thomas & Leitner Orthodontics

  • Patient Information

  • If Patient is a Minor

  • NameBirthdate 
  • Responsible Party

  • If the patient's responsible party is themselves, insert the patient's name
  • Please provide full address with City, State and Zip.
  • Spouse's Information

  • Primary Insurance Information

  • Secondary Insurance Information

  • Emergency Contact Information

  • Medical History

  • MM slash DD slash YYYY
  • Dental History

  • MM slash DD slash YYYY
  • Authorization and Release

  • TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED AND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE THOMAS & LEITNER ORTHODONTICS PERMISSION TO PERFORM THE NECESSARY DENTAL SERVICES THAT THE PATIENT MAY NEED.
  • PHOTO RELEASE

    WE WILL BE DOCUMENTING YOUR SMILE TRANSFORMATION WITH PHOTOS, POSSIBLE VIDEOS AND DENTAL MODELS TO CELEBRATE YOUR RESULTS. WE OCCASIONALLY SPOTLIGHT PATIENTS ON OUR WEBSITE, WITHIN THE OFFICE, AND OTHER PRACTICE SITES (FACEBOOK, BLOG, ETC) AND REQUEST YOUR AUTHORIZATION BELOW. I, THE UNDERSIGNED, DO HEREBY RELINQUISH ANY AND ALL RIGHTS TO PHOTOGRAPHS, PORTRAITS, PRINTS, NEGATIVES, OR OTHER PHOTOGRAPHIC REPRODUCTIONS CAPTURED WITH STILL MOTION PICTURE, VIDEO, DIGITAL OR OTHER CAMERAS FOR USE BY THOMAS & LEITNER ORTHODONTICS.
  • Acknowledgement of Receipt of Notice of Privacy Practices

    *You may refuse to sign this agreement.
  • I have received a copy of this office's notice of privacy practices.
  • This field is for validation purposes and should be left unchanged.

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