1. Tell Us ABOUT Your Child
  Last First MI
2. Who is Accompanying Your Child to their appointment?
Parent's Marital Status:
3. Mother's Information
Father's Information:
4. Person Responsible For Account
City State Zip
Who is responsible for making appointments?
5. Dental / Orthodontic Insurance
secondary Dental / Ortho Insurance

Any additional insurance information can be given via email to smile@bohmanortho.com or phone at 720-887-8357.

What are the main concerns that you would like orthodontics to accomplish?
For each question, include a field for 1-5.
Please rate the following aspects of orthodontic treatment using the scale of importance below:
(1) Not important (2) Somewhat important (3) Important
(4) Very important (5) Extremely important

Please Describe your chil's current physical health:
Please list all drugs that your child is currently taking:

Please list all drugs that your child is allergic to:
7. Has your child ever had any of the following medical problems?

Please discuss any medical problems that your child has had:
8. Does/did your child have any of the following habits?

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.


I authorize the dental staff to perform the necessary dental services my child may need.