Registration and health history

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We are looking forward to helping you with straighter teeth with braces in South Brunswick, NJ. Please complete this patient registration and health history for Smile Logic Orthodontics.

Email *

Name of person signing on behalf of the patient *

Date *

YYYY

Electronic signature consent *

I consent to the use of electronic records and electronic signatures in place of written documents and handwritten signatures as described at https://www.smilelogicortho.com/esign/

Required

Electronic communication authorization *

I authorize and consent to receive unencrypted email communication as described at https://www.smilelogicortho.com/electronic-communication-authorization/

Required

HIPAA acknowledgement *

I have received or been offered a copy of the “Notice of Privacy Practices” to read at https://www.smilelogicortho.com/hipaa-privacy-notice/, and any questions I had were answered to my satisfaction.

Required

Informed Consent *

I consent to an orthodontic evaluation.

Required

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