Welcome
to the orthodontist

Our goal is to help ypur 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 

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

I authorize the dental staff to perform the necessary dental services that my child may need.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office.