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Submit Your Health History Form Online to Your Orthodontist

Take about 10 minutes to fill out this confidential health history form and save time at your initial visit. Click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption so that we will be able to review your information prior to your initial visit. We will ask that you provide a signature at the office to verify that the information you submitted online is accurate.
ATTENTION: All information that contains an astrix needs to be completed in order to submit the forms, If there is any information that you are unable to complete, please enter some form of information (ex: General Dentist's Phone Number (000) 000-0000).

Patient Information

Items marked with asterisk (*) must be completed.
years old
Patient's Address*
Previous Address (if<5 years)
Ethnicity*

Responsible Party Information

Residence
If patient is under 18 or you would link to add a second responsible party, please complete this section.
Residence

Dentists/Physicians

Dentist's Address
Physicians's Address


Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Please check any of the following that you have had or currently have:
Please check any of the allergies or reactions to any of the following:
Please list all of the Medications (what they are taken for), Nutrient Supplementation, Herbal Medications or Non-Prescription Medicine:
female patients only
FOR CHILDREN under 18 years of age

Family Medical History

Do the patient's parents or siblings have, or have ever had any of the followign health problems? If so, please explain.

Dental History

Now or in the past, has the patient had (Please check all that apply):

The Final Details

Thank you for completing the Medical History/New Patient Form. Please hit the submit button below and the forms should be submitted directly to our practice. We appreciate your time and look forward to meeting you!


By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.