Area's only board certified orthodontist, with over 19 years of experience

Patient Health History Form

Patient History and Release Form

Please check all that apply

 

Dental History

Yes











Medical History

Has patient had or have any of the following?

Yes






















Please inform us if any changes occur to the patient's medical history.

Patient Information
Patient's Name
Address
Responsible Party Information
Name
Residence
Mailing Address
* Home Ownership?
Previous Address (if less than 3 yrs.)
Spouse's Name
Insurance Information

 
Emergency Information

I understand that where appropriate, credit bureau reports may be obtained.

 

 

Authorization to Release Orthodontic Needs

Rosenthall Orthodontics is dedicated to our patients. Our goal is to give our patients the best possible treatment with the least inconvenience, using the most advanced treatment techniques and materials. We strive to exceed our patient's expectations in every aspect of their orthodontic treatment.

It is the policy of our office not to release patient information about you or your child unless it is for patient care and treatment or payment. Our office is an open bay concept. We try, to the best of our ability, to keep the discussion of patient information to a minimum. If you wish for Dr. Rosenthall and/or office staff to leave messages for you on your home telephone, message number, answering machine, work telephone, voice mail, cell phone or pager, or to any other person, then you must sign the following:

I authorize Mark R. Rosenthall, DDS, MSD or staff to release patient information about me/my child and agree it is my responsibility to notify the staff whenever I want this to change.

You may also disclose information to my family members and non-family members listed by name and relationship.



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Rosenthall Orthodontics

  • Muncie Location - 3901 N. Wheeling Ave., Muncie, IN 47304 Phone: 765-289-2377
  • Pendleton Location - 6535 S. State Rd. 67, Ste. 100, Pendleton, IN 46064 Phone: 765-374-5365

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