GETTING TO KNOW YOU...
title
First Name
Middle Name
Last Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
Area Code
Phone Number
Date
Area Code
Phone Number
IF UNDER 18
First Name
Last Name
First Name
Last Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
First Name
Last Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance - Primary
Area Code
Phone Number
Insurance - Secondary
Area Code
Phone Number
Nearest relative not living with you:
Area Code
Phone Number
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country:
Medical History:
Area Code
Phone Number
Do you have any of these conditions?
If Female, do you have any of these conditions?
Dental History
First Name
Last Name
Office Name
Street Address
City
State / Province
Postal / Zip Code
Area Code
Phone Number
Please answer the following
Please answer the following
What Phone Carrier Do You Use
When was your last dental cleaning?
Assignment and Release

Release and Waiver: I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
I have read and understand the above questions. My orthodontist or any member of his/her staff are not held responsible for any errors or omissions that I have made in the completion of this form. Any changes in my medical or dental health, I will notify my orthodontist.