New Patient Information

  • New Patient Information - Child

  • Patient Gender*
  • Patient Identifies As
  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parent's Marital Status
  • Person responsible for account
  • Which method(s) would you prefer to receive notifications of future appointments? Check all that apply.*
  • Has parent and/or siblings had previous orthodontics?
  • What concerns you most about the child's teeth?*
  • Most interested in:
  • Date of last visit*
     - -

  • Dental Insurance Information

    If you have dental insurance, please provide the following information so we can verify your benefits before your scheduled appointment.  

  • Policy Holder's Date of Birth
     - -
  • Format: (000) 000-0000.
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  • Medical History

  • Has the patient ever had any of the following medical concerns? (Check all that apply)*
  • While sleeping does the patient: (Check all that apply)*
  • Have you ever seen the patient stop breathing during the night?*
  • Does the patient? (Check all that apply)*
  • Does the patient wake up feeling unrefreshed in the morning?*
  • Does the patient have a problem with sleepiness during the day?
  • Has a teacher or other supervisor commented that the patient appears sleepy during the day?*
  • Is it hard to wake the patient up in the morning?*
  • The patient often: (Check all that apply)*
  • Is the patient allergic to any of the following? (Check all that apply)*
  • Has the patient ever had any of the following dental concerns? (Check all that apply)*

  • Growth Information for Patients Under 16 Years of Age

  • Has your son or daughter reached puberty?
  • Girls - Has she started menstruation?
  • Date menstruation started (Please estimate if unknown)
     - -
  • Boys - Has his voice changed?
  • Date voice changed (Please estimate if unknown)
     - -
  • Adopted?

  • I certify that the above information is complete and accurate.  I also understand that I am responsible for updating any changes or additions to this information in the future.  

  • Today's Date
     - -

  • Consent to Use Records

    I hereby assign and grant to Cunningham Orthodontics, P.C. the right and permission to use and publish for the use of orthodontic records, including photographs, made in the process of examinations, treatment and retention for purposes of professional consultations, research, education or publication in professional journals and local advertisements.  

    I hereby assign and grant to Cunningham Orthodontics, P.C. the right and permission to use and publish and tag photographs on social media, made in the process of examinations, treatment and retention.  

  • Consent of Records*
  • Date*
     - -

  • ***FOR DRIPPING SPRINGS HIGH SCHOOL STUDENTS ONLY***

    Waiver and Release of Liability, Assumption of Risk and Parental Consent and Indemnity Agreement

    I believe the Minor to have such experience, maturity level and capability to leave for their orthodontic appointment from Dripping Springs High School (DSHS) campus to Cunningham Orthodontics, P.C. and return to Dripping Springs High School.  I agree and warrant that I will instruct the Minor that if at any time the Minor believes conditions to be unsafe, he/she will immediately discontinue leaving Dripping Springs High School campus without parent present.  

    I fully understand that leaving Dripping Springs High School campus involves risks and dangers that could be caused by the Minor's own actions, the inactions of others participating in the off-campus priviledge or of others associated with Dripping Springs High School or Cunningham Orthodontics, P.C.


    I HEREBY RELEASE, DISCHARGE, CONVENANT NOT TO SUE, AND AGREE TO INDEMNIFY, SAVE AND HOLD HARMLESS CUNNINGHAM ORTHODONTICS, P.C., DR. CARLY C. CUNNINGHAM, AND/OR ALL EMPLOYEES OF CUNNINGHAM ORTHODONTICS, P.C. FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES OR DAMAGES ON THE MINOR'S BEHALF WALKING FROM DRIPPING SPRINGS HIGH SCHOOL.

    I HAVE READ THIS AGREEMENT AND GIVE MY MINOR CHILD PERMISSION TO WALK FROM DRIPPING SPRINGS HIGH SCHOOL TO CUNNINGHAM ORTHODONTICS, P.C., AND RETURN BACK TO DRIPPING SPRINGS HIGH SCHOOL.  

    I ALSO UNDERSTAND THAT IT WILL BE MY RESPONSIBILITY TO CALL THE OFFICE IF ANY QUESTIONS OR CONCERNS ARISE ABOUT HIS/HER TREATMENT IF I DO NO ACCOMPANY MY CHILD TO THEIR ORTHODONTIC APPOINTMENTS.

  • Would you like your child to receive text message reminders of their appointment?
  • Format: (000) 000-0000.
  • Should be Empty: