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
• Notice of Privacy Practices

New Minor Patient Forms:

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

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Existing Patients

Thank you for choosing Rafati Orthodontics! If you have visited Rafati Orthodontics 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
• Notice of Privacy Practices
• Update Orthodontic Insurance Form

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Referring Doctors

 Referring Doctors Forms:

• Doctor's Referral Form
• Smile Certificate

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Compliant Opt-In Verbiage: "By providing a mobile number, I agree that Rafati Orthodontics may send automated appointment and dental marketing messages to the number provided. I understand consent is not required for purchase.”

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Give us Feedback

To provide the quality of services you expect, we are open to your feedback and suggestions about your recent visit or experience with Rafati Orthodontics. 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.