• Child Patient Form

  • We would like to welcome you and your child to our office. Our goal is to make everyone's visit pleasant, stress-free and educational. We pride ourselves in creating beautiful smiles that lasts a lifetime. We look forward to seeing you in the office.

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  • Custodial Parent Information

    Patient Information
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  • Additional Parent Information

  • Primary Orthodontic Insurance

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  • Secondary Insurance

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  • What are the main concerns you or your child's dentist would like orthodontics to address?

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  • Medical History

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  • Emergency Contact

    Please list an emergency contact not living with you
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  • Clear
  • Should be Empty: