Welcome
to the orthodontist

A beautiful smile is a wonderful asset. Please fill out this form completely. The better we communicate, the better we can care for you.

1About You

LAST
FIRST
MI
City
State
Zip
City
State
Zip

2Spouse Information

3Orthodontic Insurance

Primary
Secondary
in the event of an emergency, whom should we contact?

4Medical History

4Medical History Cont.

Have you ever had any of the following diseases or medical problems?
Are you allergic to any of the following:

5Dental History

I

understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Thank you for filling out this form completely.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.