New Patient Forms, Health and Dental History

New Patient Intake Forms

Otter Orthodontics New Patient Forms and Health History
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
Preferred Pronouns
Responsible Party's Name*

First NameLast Name
Responsible Party's Relationship to Patient*
Mother, father, self, etc.
Responsible Party's Date of Birth*

MonthDayYear
Patient or Responsible Party's Email Address*
example@example.com
Patient or Responsible Party's Cell Phone*
Please enter a valid phone number.
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party's Address (if different from patient's, leave blank if the same)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about our office?*
Friend, family member, dentist, internet, etc.
Is this your first time visiting an orthodontist?*
What are your orthodontic concerns?*
example: underbite/overbite, issues eating, aesthetics, etc.
Patient's General Dentist*
Date of patient's last cleaning and/or exam*
Dental Insurance Information

Please type "n/a" for all required boxes if no insurance information is available. We offer flexible in-house and third party financing for all patients and strive to create individualized financing plans for all regardless of insurance status. You can also text a photo of both sides of your dental insurance card(s) to 503.659.5000.
Name of Insurance Company*
Name of Subscriber/Card Holder*
Subscriber DOB*
Subscriber's Relationship to Patient*
Subscriber or Member ID*
Group Number and/or Name*
Subscriber's Employer*
Insurance Company Phone #*
Social Security Number if METLIFE Insurance*
type n/a if you do not have MetLife insurance

New Patient Intake Forms

Dental Insurance Information

Patient's Medical History