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23900 Hwy 59, Kingwood, TX 77339

Paige Orthodontics
Paige Orthodontics
Paige Orthodontics
Mon: 8:00am-6:00pm
Tues & Wed: 8:00am-5:00pm
Thur: 7:30am-5:00pm
Fri: 8:00am-4:00pm (Available for Phone Calls Only)
Sat: 8:00am-1:00pm (By Appointment Only)

281-358-6580

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New Patient Form

1 PATIENT INFORMATION
2 RESPONSIBLE PARTY INFORMATION
3 INSURANCE INFORMATION
4 MEDICAL HISTORY
5 DENTAL HISTORY
  • PATIENT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • RESPONSIBLE PARTY INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • INSURANCE INFORMATION

  • Date Format: MM slash DD slash YYYY
  • As a courtesy to our patients we file your insurance claim forms. We will attempt to obtain as much insurance coverage for you as possible. However, please understand that you are responsible, in full, for all charges rendered. Any insurance estimates provided by this office should be considered a guideline only. When final insurance payment is received, your account will be reconciled. I authorize the release of any information necessary to process my insurance claims and, also herby authorize payment of insurance benefits to Paige Orthodontics.
  • Date Format: MM slash DD slash YYYY
  • MEDICAL HISTORY
  • Your answers to the following questions are extremely important for an accurate diagnosis. Thank you for your patience in answering the following questions:

  • DENTAL HISTORY

  • NOTE: We make every attempt to schedule appointments for convenience, but orthodontics appointments may infringe on your school/ work schedule.

  • I understand that records are stored electronically and that an electronic copy shall be considered an original for all purposes.

  • Date Format: MM slash DD slash YYYY
  • ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION.

    By law, we are required to provide you with our Notice of Practice. Please sign below acknowledging your receipt of this information. This shall also serve as consent to use and/or disclose your protected health information to carry out treatment, payment activities, and health care operations. If you should have any questions regarding this Notice and consent, you may contact: Paige Orthodontics at 281-358-6580

  • Date Format: MM slash DD slash YYYY
Paige Orthodontics

23900 Hwy 59, Kingwood, TX 77339

281-358-6580

Fax: 281-358-4055

Office@PaigeOrthodontics.com

HOURS

Mon: 8:00am-6:00pm

Tues & Wed: 8:00am-5:00pm

Thur: 7:30am-5:00pm

Fri: 8:00am-4:00pm (Available for Phone Calls Only)

Sat: 8:00am-1:00pm (By Appointment Only)

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