Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

PATIENT REGISTRATION FORM

Soleil Orthodontics

17000 140th Ave NE #204,
Woodinville, WA 98072
(425) 979-2080

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )

Whom may we thank for referring you to our office?

Orthodontic Insurance Information( * mandatory to fill )
  •  Yes
  •  No
Secondary Orthodontic Insurance Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Patient Medical History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
Patient Dental History( * mandatory to fill )
  •  Yes
  •  No

Has the patient had (past or present) any of the following habits:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Has the patient ever been evaluated or treated for:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Has the Patient ever had any of the Following?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Bisphosphonates

(Adult patients only)

Bisphosphonates are sometimes marketed as Boniva, Fosamax, Fosamax+D, Actonel, Reclast,

Actonel+Ca, Aredia, Didronel, Skelid, and Zometa.

 

  •  Yes
  •  No
Acknowledgement( * mandatory to fill )

Benefits of Orthodontic treatment include aesthetics, health, and function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay, decalcification, and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I understand that my diagnostic records and my name may be used for educational purposes. I also understand that orthodontic appointments are often during work and/or school hours. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. Soleil Orthodontics will not be held responsible for any problems arising out of inadequate or undisclosed information. In addition, I authorize Dr. Roberts to perform a complete orthodontic evaluation.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.194.190 )
ORTHODONTIC FINANCIAL AGREEMENT - For professional services rendered( * mandatory to fill )

Option #2 - Payment Plan

This treatment fee covers all orthodontic appliances necessary for the recommended treatment, routine adjustments during the course of treatment, removal of the braces, placement of retainers, and two years of retainer checks. Broken or lost retainers and alterations to the treatment plan by patient request may be subject to additional fees. The number of financed monthly payments has been established as courtesy and does not correspond to the length of orthodontic treatment.

**We are pleased to assist you with predetermining your insurance benefits and submitting claims to your insurance company on your behalf. If your insurance benefits terminate, or if any portion of the anticipated benefits are not paid by your insurance, all remaining charges will be applied directly to the responsible party.

AGREEMENT

a) I agree to the above financial contract.

b) I give authorization to Soleil Orthodontics to bill my insurance for services provided.

c) I agree to assume responsibility of all treatment charges outlined above, including any portion of anticipated insurance payments not paid directly to Soleil Orthodontics due to misdirection of funds or loss of insurance coverage.

 

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.194.190 )
Copyright ©2019 SRS Web Solutions
Your browser doesn't support signing