11811 Hinson Rd.
Little Rock, AR 72212

2924 Kavanaugh Blvd.
Little Rock, AR 72205

2906 Cypress Rd.
Arkadelphia, AR 71923

Tell Us About Your Child
Last / First / M. / Ini.
City / State / Zip
Who Is Accompanying The Child Today?
Parent's Information
Person Responsible For Account
City / State / Zip
Primary Dental Insurance
Does/did the Child Have Any of the Following?
What would you like orthodontics to accomplish?
Has your child ever had any ofthe following medical problems:

I understand that the information that I have given is correct to the best of my knowledge, that is 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.

Signature of parent or guardian

This office reserves the right to verify the credit status of potential patients and/or prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting agencies.

Signature of parent or guardian