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McAllister Orthodontics | Omaha & Fremont, NE
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  • Patient Health History Form

Patient Health History Form

1 Step 1 of 4 : Patient Info
2 Step 2 of 4 : Dental Insurance and Authorization
3 Step 3 of 4 : Dental and Medical History
4 Step 4 of 4 : The remainder of the form
  • Date Format: MM slash DD slash YYYY


  • Patient Information

  • Date Format: MM slash DD slash YYYY


  • Responsible Party Information

    (for patients under the age of 18)

    Responsible Person

  • Date Format: MM slash DD slash YYYY


  • Spouse

  • Date Format: MM slash DD slash YYYY


  • Dental Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY


  • I authorize the following

    1) The release of dental records or other information to process any claims filed by this office for services rendered. 2) Payment of dental benefints to Dr. Paul McAllister. 3) This copy of my signature to be sent with my insurance claims.



  • Dental History

  • Date Format: MM slash DD slash YYYY


  • Medical History



  • I prefer to be contacted during the day by:

  • This field is for validation purposes and should be left unchanged.
McAllister Orthodontics | Omaha & Fremont, NE
Best of Omaha winner 2019 & 2018
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Latest Updates Regarding COVID-19

 

We are pleased to announce that the Nebraska Directed Health Measures which have required us to close over the past several weeks will expire at the end of this week, and we will OPEN our Omaha and Fremont offices for patient care starting this coming MONDAY, MAY 4th, 2020!  We appreciate your patience with us as we have done our part to help keep our community safe these past several weeks.

As we now begin to see patients again, we want you to know that we are committed to your health and safety.  We will provide a safe environment for your care by continuing to maintain the highest standards of infection control in our disinfection and sterilization procedures.

For additional information on how we plan to take the extra precautions, and how to check-in for an appointment, please click here.