We would like to welcome you to our office. Our goal is to help you achieve a beautiful smile and while reaching and maintaining maximum oral health in a warm, courteous, safe and caring environment. Please fill out these forms completely.

Medical History

Ever had the following medical problems?


Dental History

Ever had?

Ever experienced?

Any of the following habits?

As a courtesy and service to our patients we will provide a “super bill” that you may submit with your claim form for reimbursement from your insurance company. We do not accept assignment of benefits from the insurance companies.

It is important to attend appointments. Please understand that a last minute cancellation or “no show” does not allow us enough time to accommodate another patient. Because the time we allot is valuable, kindly give our office 24 hours notice if you must cancel an appointment. We reserve the right to charge a $150.00 for every 30 minutes for any appointment not cancelled within 24 hours.

I understand that I am responsible for all costs of orthodontic treatment and that in the event of a default of one of the responsible parties/parents, I am entirely responsible for all costs of orthodontic treatment and will pay them in a timely manner.

Signature of Responsible Person(s)

Signature of Responsible Person(s)