Welcome

We would like to welcome you and your child to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Patient Information

Gender:
Marital Status:

Spouse / Additional Contact Information

Marital Status:

Insurance Information

Secondary Insurance

Medical History

Are you under the care of a physician?
Are you pregnant?
Have you ever been evaluated for orthodontic treatment?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to: (select all that apply)
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do/Have you have/had any of the following habits?
Are you allergic to any of the following?

Signature

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this once of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the once. I understand that where appropriate, credit bureau reports may be obtained.

Human Verification

Please enter the verification codes listed below to continue with submitting your form.