New Patient Welcome Form | Go Clear Orthodontics Logo
  • WELCOME TO OUR PRACTICE!

    To assist us in providing the most amazing and complete service, please provide the following information and health history.
  • PARENT INFORMATION (IF MINOR PATIENT)

  • PRIMARY DENTAL INSURANCE

  • SECONDARY DENTAL INSURANCE

  • Go Clear Orthodontics

    259 Textile Way ° Suite 103 ° Fort Mill, SC 29715

    Phone 803-650-3068

    www.goclearorthodontics.com

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  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. 

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  • I understand that I am responsible for payment of services rendered. I understand that I am responsible for paying any costs that my insurance will not cover. I also understand that insurance pays over my treatment time, and may not pay in full up front. If I change or lose my insurance for any reason during my treatment, I will be responsible for any charges remaining on the account.

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