AAO CRB
New Patient Form
If you are new to our practice...

Patient Information Form

Patient Information and History Form

In order to protect your health, safety, and privacy, and to help ensure a successful treatment, we ask all new patients to fill out a simple four-page questionnaire that asks for contact info, a brief medical history, and details about dental insurance coverage (if applicable). The form also includes a HIPAA Notice of Privacy Practices, which you should read carefully.

You may fill out the form when you first come into our office to begin treatment. However, for your convenience, we have made this form available on the website in Adobe Acrobat PDF format so that you can fill it out at home.

Instructions

To begin, download the form to your computer desktop by right-clicking on the link. You can then fill out the form in two ways.

Offline Method

  1. Double-click the form to open it in Adobe Reader.
  2. Print the form.
  3. Fill it out manually with a ballpoint pen (not a pencil), sign and date it, and bring the completed form to our office on your next visit.

Online Method

  1. Double-click the form to open it in Adobe Reader.
  2. With your mouse, click inside the first empty field on page 1 (“Patient’s Last Name”) and start typing the required information.
  3. Tab or click through the form to fill out all the remaining fields, including checkboxes. Note that some fields (e.g., patient’s name) must be filled in.
  4. Once completed, click Save in the FILE menu to save the information you have provided in the form.
  5. Print the completed form, sign and date it, and bring it with you to our office on your next visit.

    OR

    You may attach it manually to an email addressed to ss@capitalregionbraces.com We will print it out for you, and then have you sign it on your next visit.

If you have any questions about filling out this form, please do not hesitate to call one of our offices for assistance.

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To view this PDF form, you need the free Adobe Reader application. If it is not already installed on your computer, please click on the icon below to download it.

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  Capital Region Braces  
Specialists in Orthdontics

in Upstate New York

Burnt Hills

518.384.0416

Clifton Park

518.383.5457

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