Adult New Patient Form

Nearest Relative not living with you

If you have Dental Insurance Coverage, please fill out below:

If you have Dental Insurance Coverage, please fill out below:

Bailey Orthodontics utilizes Facebook, Instagram, Twitter, YouTube, Google, and other social media platforms for the free exchange of information and customer service as well as marketing. At times, we will take pictures of our various patients during their treatment or other interactions and potentially post them to various social media outlets that we use, as well as to our website. We will not post a picture of your child or yourself without your consent, nor will we use any photos taken and used for confidential patient records. I (name) give my consent to Bailey Orthodontics for myself or child to use pictures or video that include myself or child in their various social media campaigns. By signing, I understand that Bailey Orthodontics may still use pictures of myself or child even after treatment has concluded.