• New Patient Form

    Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

  • Patient Information

  • Who are you filling this form out for?*
  • Birthdate*
     - -

  • Responsible Party Information

  • Is the responsible party the same as above?*
  • Is the address the same as patient*
  • Is the phone the same as the patient's?*
  • Birthdate*
     - -
  • Birthdate
     - -

  • Dental Insurance Information

  • Do you have Dental Insurance?*
  • Birthdate*
     - -
  • Do you have dual coverage?*
  • Insured's Birthdate*
     - -

  • Emergency Contact Information

  • What are the main concerns that you would like the orthodontist to address?

  • Date Of Last Dental visit
     - -
  • Past Dental Facial Trauma*
  • Have there been any injuries to the face, mouth, teeth or chin?*
  • Major Accidents Or Surgery Involving The Neck, Mouth Or Teeth?*
  • Teeth Broken, Loosened or Knocked out?*
  • Missing Teeth?*
  • Jaw Joints Problem?*
  • Locking?*
  • Pain?*
  • Noise?*
  • Discomfort Opening Or Closing?*
  • Frequent Headaches?*
  • Clenching Or Grinding?*
  • Oral Problems*
  • Canker / Cold Sores*
  • Swollen/Bleeding Gums*
  • Hepatitis*
  • Speech*
  • Habits Thumb/Finger*
  • Mouth Breathing*
  • Difficulty chewing or swallowing food?*
  • Previous Orthodontic treatment/consultation*
  • Siblings have/had orthodontics
  • Parents have/had orthodontics
  • Which Parent?
  • Does Patient Stature, Teeth, or Mouth Resemble*
  • Does Anyone Else In The Family Have a Similar Dentofacial Condition: Crowded, Retruded, Or Protruded Teeth, Protruding Lower Jaw, Receding Chin*

  • Medical History

  • Present Health*
  • Hospitalized In The Last Three Years*
  • Operations*
  • Tonsils Removed?*
  • Adenoids Removed?*
  • Chronic Disease*
  • (Lung, Liver, Heart, Kidney e.t.c)*
  • Presently Under Care Of Physician?*
  • (Diabetes, Hepititis, High/Low Blood Pressure)*
  • Any medication currently being taken?*
  • Allergies*
  • Complications To Previous Treatment*
  • Excessive Breathing, Fainting, Drug Reaction*
  • Does The Patient Smoke*
  • Or Use Any Tobacco Products*
  • Asthma*
  • Congenital Heart Defect*
  • Heart Murmur*
  • Hemophilia*
  • HIV+/AIDS*
  • Emotional Problems*
  • Rheumatic/Scarlet Fever*
  • Tuberculosis (TB)*
  • How were you referred to our practice?*
  • Which office will you be visiting?*

  • Signatures

  • Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!

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