Logo
Confidential Biographical Information
Confidential Financial Party Information
Dental Insurance Information
Emergency Information
Dental History
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Medical History
Allergies or drug reaction to:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth - If your teeth could be changed, how would you like them to change?

Face - If your facial appearance could be changed, what would you change?

Symptoms - If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.

Patients Under 18

If patient is under the age of 18, please answer the following questions:

Signature