Welcome
to the orthodontist

Our goal is to help your child reach and maintain good oral health and a beautiful smile that lasts a lifetime.

1Tell Us About Your Child

LAST
FIRST
MI
APT/CONDO#
CITY
STATE
ZIP

2Who Is Accompanying Your Child Today?

3 Parental information

4Person Responsible for Account

CITY
STATE
ZIP
CITY
STATE
ZIP

5Primary Orthodontic Insurance

Secondary Orthodontic Insurance

6 

7Has Your Child Ever Had Any Of The Following Medical Problems?*

8Has Your Child Ever Experienced Any Of The Following?*

CITY
STATE
ZIP

9