New Patient Form

Submit your health history form online to your orthodontist today.

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

Patient Information


Person Responsible For Account


Dental Insurance Information

Primary Insurance Information

Secondary Insurance Information

Emergency Information


What are the main concerns that you would like orthodontics to address?


Has the patient ever had any of the following medical problems?


Does/Has the patient have/had any of the following habits?


Signatures



The Parent or Guardian who accompanies the child is responsible for payment. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.


Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!