PATIENT FORMS

We look forward to seeing you in our office at your upcoming appointment. To allow us to spend as much time as possible with you during your visit, we ask that you complete your patient forms on our secure online platform prior to your appointment. Thank you for taking the time to prepare for your office visit so we can provide you with the best care possible!

FORMS FOR EXISTING PATIENTS

Please complete the following required forms just prior to your appointment.

Complete one time by every patient
starting 05/01/2020

Complete prior to every appointment
starting 05/01/2020

FORMS FOR NEW PATIENTS

Please read our Welcome Message and complete the following required forms just prior to your initial appointment.

Complete one time
prior to initial appointment

Complete prior to every appointment
starting 05/01/2020

If you have questions about our online forms, please call or email our office.

ADDITIONAL FORMS

ACQUAINTANCE FORM - CHILD

For adolescent patients, parents/guardians please take a moment to download, print and fill out completely the Acquaintance Form. Please bring this form with you to the first appointment. This form gives us an overview of the patient’s dental and medical history.

ACQUAINTANCE FORM - ADULT

For adult patients, please take a moment to download, print and fill out completely the Adult Acquaintance Form. Please bring this form with you to the first appointment. This form gives us an overview of your dental and medical history.

WELCOME! INTERESTS FORM

Dr. Siu loves to get to know his patients! He has shared some of his favorite interests on the Welcome! Interests form. Did you know he loves badminton? Kids, if you could take a moment to fill out this form with some of your hobbies, favorite foods, sports you like to play and any other interests, that’d be great! Bring it with you to your first appointment. We look forward to getting to know you!

PRIMARY INSURANCE

This form is used to verify Orthodontic Coverage with your Primary Insurance Carrier. Please complete the Primary Insurance Coverage Section, Employer Information Section and the Subscriber Information Section. You will also need to bring your current Dental Insurance Card to the initial appointment.

SECONDARY INSURANCE

This form is used to verify Orthodontic Coverage with your Secondary Insurance Carrier. Please complete the Secondary Insurance Coverage Section, Employer Information Section and the Subscriber Information Section. You will also need to bring your current Dental Insurance Card to the initial appointment.

Address

115 Alpine Ct, Shawano, WI 54166, USA

Contact

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Toll Free: (866) 526-2544

(715) 526-2544

© 2020 BY SHAWANO ORTHODONTICS. ALL RIGHTS RESERVED.