New Patient Form

Submit your health history form today!

Take a few minutes to fill out this confidential form and click “submit”. Your information will be sent to our office with secure encryption.
No consultation scheduled yet? No problem - once you submit your form, you can either call us to set up your free new patient exam or our front office will reach out to you soon to set up your appointment. Presione aquí para obtener el formulario en español.

Patient Information

Person Responsible For Account

Dental Insurance Information

Primary Insurance Information

Secondary Insurance 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?


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!