Forms

New Patients

Thank you for choosing Rafati Orthodontics! Download and print new patient forms below.

New Adult Patient Forms:

• Adult Medical History Form
• HIPAA Privacy Form
• Orthodontic Insurance Information
• Orthodontic Insurance Form

New Minor Patient Forms:

• Minor Medical History Form
• Get to Know You Better Form
• HIPAA Privacy Form
• Orthodontic Insurance Form

 These forms require Adobe Acrobat Reader to view. If you do not have Adobe Reader already installed on your computer, click the Adobe logo to download.

Existing Patients

Thank you for choosing Rafati Orthodontics! If you have visited our office previously, see below. 

Existing Patient Forms:

• Smile Certificate
• Headgear Hours Form
• Orthodontic Insurance Information
• Orthodontic Insurance Update Form
• Adult Medical History Update Form
• Minor Medical History Update Form

 These forms require Adobe Acrobat Reader to view. If you do not have Adobe Reader already installed on your computer, click the Adobe logo to download.

Referring Doctors

 Referring Doctors Forms:

• Doctor's Referral Form
• Smile Certificate

 These forms require Adobe Acrobat Reader to view. If you do not have Adobe Reader already installed on your computer, click the Adobe logo to download.

Give us Feedback

In order to provide the quality of services you expect, we are open to your feedback and suggestions about your recent visit or experience with our office. If you have had an enjoyable experience, let us know. If you have had an unfavorable experience, please share your thoughts on how we might improve our services. Your feedback is valuable to us, and we will do our best to accommodate your requests. Please fill out the form below and include contact information, so that we may contact you to address any outstanding issues.