• Patient Information

  • Gender*

  •  -
  • Type

  • Spouse / Partner Information

  • Marital Status
  •  -

  • Dental History

  • Date of last visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Where did you hear about us?*

  • Have you visited an orthodontist before?*
  • When?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have your tonsils or adenoids been removed?*
  • Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?*
  • Have you ever had an injury to (select all that apply)*
  • Do you have speech problems?*
  • Do your gums bleed?*
  • Do you like your smile?*
  • Do you currently or have you ever had any of the following habits (check all that apply)*

  • Medical History

  • Are you currently being treated by a physician?*
  • Last visit
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Do you have any allergies/sensitivities to medications or latex?*
  • Are you currently taking any prescription or over-the-counter medications?*
  • Check if you have or have ever had any of the following*

  • Dental Insurance Information - Primary

  •  -

  • Dental Insurance Information - Secondary

  •  -

  • 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 of confidence and it is my responsibility to inform the office of any changes in my dental status.

    I hereby authorize the release of any information pertaining to my dental treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • Should be Empty: