Intake Ortho

Patient Intake Form – Orthodontics

We welcome you as a new patient and are excited to serve you!

Please complete this form as accurately as possible. It is important for us to have this information in order to provide the best possible care for you/your child. Your privacy is important to us. The information you share with us will remain strictly confidential.

Important note:  This page is secured and encrypted using AES_256_CBC, with HMAC-SHA1 (same as the U.S. government) for message authentication and RSA as the key exchange mechanism..

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Orthodontic Financing in North Carolina - MyOrthodontist
CareCredit Orthodontic Financing - MyOrthodontist
Lending Point Orthodontic Financing - MyOrthodontist

MyOrthodontist Offers Affordable Orthodontic Financing Through Care Credit and Lending Point!

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