Welcome Form

Welcome to Periago Orthodontics

All of us here at Periago Orthodontics are excited that you are coming in for a visit! We want you to know that your appointment will be fun and painless! While you are here, Dr. Periago will determine if you need braces to help you have a beautiful and healthy smile! You’ll also learn about our patient contests and incentive programs. We’re always giving away fun prizes here at Periago Orthodontics! Please complete this form and bring it in with you to your appointment so we can get to know all about you!
TELL US A LITTLE ABOUT YOURSELF!
What is your full name?

First Name Last Name
Date

Month Day Year
Date
How old are you?
Dr. Periago got her Orthodontic Degree from the University of Louisville. What school do you go to? *
Dr. Periago liked Science and Spanish in school. What is your favorite subject? *
Dr. Periago has one brother. Do you have any brothers or sisters? (Names/Ages) *
Dr. Periago has one dog. Do you have any pets? *
Dr. Periago was on the Dance and Swim Teams in high school. Do you play any sports? *
Dr. Periago’s children play strings. Do you play any instruments? *
Our Coordinator Team, Melissa and Stacy, love sushi. What is your favorite food? *
Our entire Staff is excited to meet you! Are you excited about getting braces? *
We have patients from schools all around the community! Do you have any friends who come to our office? If so, what are their names? *
Thank you so much! We can't wait to give you a smile you love!
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Welcome to Periago Orthodontics

TELL US A LITTLE ABOUT YOURSELF!