ORTHODONTIC ASSOCIATES, INC.

260 South Eastown Road 724 East Wayne Street 1020 North Perry Street

Thomas L. Ahman DDS, MS Lima, Ohio 45807 P.O. Box 514 Ottawa, Ohio 45875

Joseph L. Janowski DDS, MS 419- 229-8771 Celina, Ohio 45822 419- 523-4014

Matthew C. Mayers DDS, MS Fax: 419-224-2514 419- 586-6195 Fax: 419-523-3058

Fax: 419-586-2875

PATIENT REGISTRATION INFORMATION

(Please type or print clearly)

PATIENT

Name______

Last First Middle Nickname

Address______

Street City State Zip (nine digits)

Dentist______Referred by______

Home Phone______Sex___Birthdate______Age_____

Soc. Sec. No. ______

Employer______Business Phone______

Orthodontic Insurance? Yes ___ No ____ Insurance Company ______

Names of other family members treated at our office______

If patient is a minor, accompanied by______

PERSONS FINANCIALLY RESPONSIBLE FOR PATIENT’S ACCOUNT (Check all that apply and complete back of form for each not listed below.)

____Patient ____Father ____Step-father ____Grandparent

____Guardian ____Mother ____Step-mother ____Other

FATHER or HUSBAND

Name______

Last First Middle

Address______

(If different than patient) Street City State Zip (nine digits)

Employer______Soc. Sec. No.______

Home Phone______Business Phone______Birthdate______

Orthodontic Insurance? Yes_____ No_____ Insurance Company______

MOTHER or WIFE

Name______

Last First Middle

Address______

(If different than patient) Street City State Zip (nine digits)

Employer______Soc. Sec. No.______

Home Phone______Business Phone______Birthdate______

Orthodontic Insurance? Yes_____ No_____ Insurance Company______

ADDITIONAL FINANCIALLY RESPONSIBLE PARTIES

GUARDIAN

Name______

Last First Middle

Address______

(If different than patient) Street City State Zip (nine digits)

Employer______Soc. Sec. No.______

Home Phone______Business Phone______Birthdate______

Orthodontic Insurance? Yes_____ No_____ Insurance Company______

OTHER FINANCIALLY RESPONSIBLE PARTY (Relationship :______)

Name______

Last First Middle

Address______

(If different than patient) Street City State Zip (nine digits)

Employer______Soc. Sec. No.______

Home Phone______Business Phone______Birthdate______

Orthodontic Insurance? Yes_____ No_____ Insurance Company______

OTHER FINANCIALLY RESPONSIBLE PARTY (Relationship :______)

Name______

Last First Middle

Address______

(If different than patient) Street City State Zip (nine digits)

Employer______Soc. Sec. No.______

Home Phone______Business Phone______Birthdate______

Orthodontic Insurance? Yes_____ No_____ Insurance Company______

To the best of my knowledge, all the above information is correct. I authorize Orthodontic Associates, Inc. to release this information to appropriate medical/dental and insurance providers.

Signature______Date______

Rev 12/13/04