Adult New Patient Information

Thank you for your interest in our services. Please fill out the information below, and one of our team members will contact you to schedule an appointment time. We look forward to seeing you soon.

Patient Information

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Spouse/Emergency Contact Information

Insurance Information

Dental History

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Medical History

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Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

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(Women)

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Check if you have or have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

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Dempsey Orthodontics

Dempsey Orthodontics - 4005 W. Figarden Dr.

Fresno, CA 93722

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