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GLYNN ORTHODONTICS | Ellen J. Glynn, DDS MDS 655 Camino de los Mares #119, San Clemente, CA 92673 / phone: 949 488 0600 email: [email protected] NEW PATIENT INFO - ADULT AND CHILD Name: ________________________________________________ Date: ________________________ Date of Birth: _________________________ Male/Female Height: ________ Weight: _________ Address: ______________________________________________________________________________ City:_____________________________ Zip Code: ________ Email:___________________________ Home Phone: _______________________________ Cell: ___________________________________ Preferred method of contacting you? _______________________________________________________ FOR CHILDREN: Mother’s Name: __________________________________ Employer: __________________________ Business Address: ______________________________________________________________________ Father’s Name: __________________________________ Employer: ___________________________ Business Address: _______________________________________________________________________ Sisters? Names and Ages: ________________________________________________________________ Brothers? Names and Ages: ______________________________________________________________ Whom may we thank for your referral? ______________________________________________________ Dentist’s Name: _____________________________ Last Dental Visit: __________________________ What is your reason for seeking an orthodontic consultation? ____________________________________ _______________________________________________________________________________________ Is there anything you’d like to change about your/your child’s smile? _____________________________ _______________________________________________________________________________________ Have there been any accidents involving your/your child’s face or teeth?___________________________ _______________________________________________________________________________________ Have you consulted an orthodontist previously? _______________________________________________ _______________________________________________________________________________________ Do you have insurance that includes orthodontic treatment? _____________________________________ Insurance Name: _____________________________ Group # _________________________________ Address: ___________________________________________ Phone: __________________________ Name of Insured: _____________________________ Relationship to patient: _____________________ Insured’s Social Security Number :____________________________ Date Of Birth: _______________ Insurance Name: _____________________________ Group # _________________________________ Address: ___________________________________________ Phone: __________________________ Name of Insured: _____________________________ Relationship to patient: _____________________ Insured’s Social Security Number :____________________________ Date Of Birth: _______________