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Instructions

Complete the form and the front desk will have your document(s) ready for your next visit.

Step 1:

Front Desk Information: Patient and Immediate Contact Information

Patient First Name *

Patient Last Name *

Mobile Number

Additional Notes/Instructions

Your Orthodontic Appointments

In order to ensure quality orthodontic care, it is imperative that both parents and patients understand the manner in which we schedule your appointments. Our goal is to be the best part of your day. We make it a top priority to value both you and your time. That’s why we make every effort to stay on or ahead of schedule. Most parents work and all children attend school. Inconveniencing your work schedule and interrupting your child’s studies as infrequently as possible is very important to our entire office. Since the vast majority of our patients are of school age, it is unavoidable that some school-time appointments will be necessary.

If in the event you are not able to schedule your appointment before or after school/work hours we can schedule on the next School Holiday or next day off of work. In doing so, there is the possibility that treatment could be delayed.

We will be glad to work around certain classes that are very important or ones in which your child may be having problems. We provide your child with school excuses for scheduled orthodontic appointments and it is important for your child to turn these in to the appropriate school official within three (3) days... We want you to know that our staff will work hard to provide the finest orthodontic care in the most convenient scheduling system possible for you and your child. We also have families and children and understand your scheduling concerns and will do everything we can to ensure that your child’s treatment goes as smoothly as possible.

LONG APPOINTMENTS, BANDING AND BONDING: These are more detailed and technique-sensitive appointments. Therefore, these appointments will be scheduled during our quieter morning hours.
EMERGENCIES: (Pain, swelling, or bleeding) This usually results from trauma to the face or mouth. These patients will be seen as soon as possible and appropriate care given or referred to another specialist for treatment.
REPAIRS: (Loose bands or brackets, broken arch wires or ties/broken appliances or retainers) These appointments are always scheduled during school hours at a specific time since they are long visits. The vast majority of your appointments over the course of treatment will be short appointments. By seeing our long-visit

Signature

Signature: Patient/Guardian

Patient Last Name *

Patient First Name *

Middle Name / Suffix

Signature (Patient/Parent)

Date