Patuxent Orthodontics
  • About Us
    • Meet The Doctor
    • Meet The Staff
    • Office Tour
  • Treatments
    • Early Treatment
    • Adolescent Treatment
    • Adult Treatment
    • Invisalign
    • Nightguards
    • Retainers
    • Sleep Apnea and Snore Guards
    • Sports Mouth Guard
    • Teeth Whitening
    • Smile Protection Plan
  • Testimonials
    • The Smile Gallery
    • Read Our Reviews
    • Write A Review
  • Patient Info
    • Schedule A Consultation
    • FAQs
    • Patient Forms
  • Blog
  • Contact Us
Select Page

Blog

No Results Found

The page you requested could not be found. Try refining your search, or use the navigation above to locate the post.

← Adolescent Treatment iTero Scanner →

Categories

  • No categories

Hollywood, MD

Phone
(240) 316-4004
Address
44220 Airport View Rd. Hollywood, MD 20636

MAP

Copyright (c) 2021 Patuxent Orthodontics

New Patient Form

Step 1 of 5

20%

  • Please fill this form out and submit it prior to your first consultation.

    For your convenience, our New Patient Forms are completely electronic – no need to print and bring in any paperwork!

    Please have your dental insurance information on hand. By providing your dental insurance information, we are able to pre-determine any orthodontic benefits prior to your initial consultation. This information will allow us to provide you a more accurate accounting of what your out-of-pocket, orthodontic investment will be.

    This form is expected to take 15-20 minutes to complete.

  • If applicable.
  • If applicable.

  • Primary Insurance

  • The information required for this section can be found on the front and back of your insurance card. If your insurance company does not provide a card, please call to find this information as it allows us to verify your benefits and coverage details before your appointment which can prevent you from paying unnecessary fees.
  • The number is located on the back of your insurance card. Please provide the "provider" number if available.
  • If no ID available, please enter "0" and call us to provide the Insured's SSN.
  • Policy Holder's Social Security Number If you do not have an insurance ID, we use your social security number to acquire benefit information. In order to protect your data, we only accept SSNs over the phone. Please call our office to provide your SSN.

  • Secondary Insurance

  • The number is located on the back of your insurance card. Please provide the "provider" number if available.
  • If no ID available, please give the Insured's SSN

  • General Health History

  • Please answer yes or no to the following:

  • General Dental History

  • If patient doesn't have one, type NONE.
  • Approximate date is acceptable.

  • Please indicate yes or not to the questions below:

  • Acknowledgment

  • I have read and understand the questions above. I will not hold Dr. Richard Lee, Loudoun Orthodontics/ Patuxent Orthodontics, or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record/dental status, I understand that it is my responsibility to inform Dr. Richard Lee as soon as I can while in treatment. I acknowledge by clicking this box that I agree to the previous statement as well as verify that my typed name below as my digital signature.

ITERO SCANNER

  • Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!

INVISALIGN

  • Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!

RETENTION

  • Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!

ADULT TREATMENT

  • Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!

ADOLESCENT TREATMENT

  • Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!

EARLY EVALUATION

  • Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!