Welcome to Marshall Orthodontics!

Welcome to Marshall Orthodontics!

Please assist us by completing the form below :)
Patient Name:

First NameLast Name
Preferred Name:
Gender:
Birthdate:

MonthDayYear
Phone Number:
For a child patient, enter a parent or guardian's mobile number. The patient's health history form will be texted to this number.Format: (000) 000-0000.
Email Address:
For a child patient, enter a parent or guardian's email address. The patient's health history form will be emailed to this address.
Mailing Address:

Street Address

Additional Address Line

CityState / Province

Postal / Zip Code
What is the main concern about the Patient's teeth or bite?

Responsible Party Information

The Responsible Party is the person who will be financially responsible for orthodontic treatment and must be at least 18 years of age.
Is the Patient the same person as the Responsible Party?
Responsible Party Name:

First NameLast Name
Relationship to Patient:
Responsible Party Contact Information
Phone Number:
Format: (000) 000-0000.
Email Address:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

HSA / FSA Funds
Do you plan to use Health Savings Account (HSA) or Flexible Spending Account (FSA) funds for treatment?

Responsible Party Information