We are so pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we'll be glad to help you. We look forward to working with you.
PATIENT INFORMATION:
What service are you interested in?
Orthodontics
Pediatrics
Wisdom Teeth Extraction
Other
Name:
Preferred Name:
Male
Female
Age:
Date of Birth:
Address:
City
State
Zip
Home Phone:
Cell:
Cell Carrier (ex: tmobile, ATT, etc)
Email:
How would you prefer us to contact you to confirm your appointment:
text
email
How did you hear about our office:
Date of Patient's Last Dental Cleaning:
Dentist/Office Name:
Has the patient previously been seen for orthodontic treatment?
YES
NO
IF YES, when?
If the patient is a MINOR, who does the patient live with?
MOM
DAD
OTHER:
EMERGENCY CONTACT:
In the event of an emergency, whom should we contact?
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
RESPONSIBLE PARTY INFORMATION:
Name:
Date of Birth:
Address (if different than above):
City
State
Zip
Cell # (if different than above):
Cell Carrier (ex: tmobile, ATT, etc)
Relationship:
Employer:
Social Security #:
INSURANCE INFORMATION:
Subscriber Name:
Date of Birth:
Social Security #:
Insurance Co:
Phone #:
Group #:
ID #:
SECONDARY INSURANCE INFORMATION:
Subscriber Name:
Date of Birth:
Social Security #:
Insurance Co:
Phone #:
Group #:
ID #:
Dental History:
Dentist/Office Name:
Date of Last Dental Visit:
Date of last Dental Cleaning:
Patient brushes teeth
(#) and Flosses
(#) times per day.
If patient is a minor, Do you ever help your child brush their teeth?
Always
Sometimes
Never
Any injuries to the mouth/teeth/head?
YES
NO
If so, explain:
Any past or current mouth habits?
Thumb sucking
Nail/Cuticle Biting
Mouth Breathing
Pacifier
Sleeping with a bottle
Other:
Patient Name:
Signature:
(If patient is minor, signature of responsible party)
Date: