• Adult New Patient Form

    Submit your health history form online to your orthodontist today. 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.
  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • SO THAT WE MAY BETTER SERVE YOU, PLEASE FILL OUT THE QUESTIONNAIRE BELOW.

    When choosing orthodontic treatment, what is important to you? Please rank the options below with 5 being extremely important and 1 not important.1= Not Important 2= Somewhat important 3= Important 4= Very Important 5= Extremely important
  • Length of treatment
  • Comfort during treatment
  • Using the latest technology
  • As aesthetics of treatment (clear braces or Invisalign)
  • A low initial fee
  • A low monthly fee
  • Quality of treatment
  • If treatment is recommended, how interested are you in starting treatment today or within the next 30 days?
  • Whom may we thank for referring you to our office?
  • Whom may we thank for referring you to our office?*

  • Medical History

  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you in good health?
  • Are you taking any medications (include over-the counter)?

  • Do you have a history of any of the following?

    Or select "None" if no history of any of these conditions
  • Medical History*

  • Are you allergic to any of the following?

    Or select "None" if no allergies
  • Allergies*
  • Have adenoid and/or tonsils been removed?
  • Abnormal Bleeding**
  • Acquired Immune Disorder**
  • AIDS/HIV**
  • Anemia**
  • Arthritis**
  • Artificial Joints or Valves**
  • Asthma**
  • Blood Disorders**
  • Blood Transfusions**
  • Cancer**
  • Cleft lip/ Palate**
  • Diabetes**
  • Difficulty Breathing**
  • Drug/Alcohol Abuse**
  • Emotional/Behavior Problems**
  • Epilepsy/Seizures**
  • Heart Disorders**
  • Hepatitis**
  • Hospitalization**
  • Kidney Disorders**
  • Lung Disorders**
  • Migraines**
  • Mitral Valve Problems**
  • Psychiatric Problems**
  • Radiation Treatment**
  • Rheumatic/Scarlet Fever**
  • Seasonal Allergies**
  • Seizures**
  • Sickle Cell Anemia**
  • Sinus Problems**
  • Sleep Problems**
  • Speech/Hearing Problems**
  • Surgery**
  • Tonsils/Adenoids/ Sinus Problems**
  • Tuberculosis (TB)**
  • Ulcers/Colitis**
  • Anesthetics**
  • Aspirin**
  • Amoxicillin**
  • Codeine**
  • Cyclosporins**
  • Erythromycin**
  • Latex**
  • Metal**
  • Penicillin**
  • Sulfa Drugs**
  • Tetracycline**
  • Vision/Hearing**

  • Dental History

  • Are there any outstanding general dental needs (fillings, crowns, etc.) at this time?*
  • Have you had previous orthodontic treatment?
  • Have you ever had problems or complications following dental treatment?*
  • Have there been any injuries or trauma to the face, mouth, teeth or chin?*
  • Have you had problems with previous dental treatment?*
  • Have you been treated by a periodontist?*
  • Have you ever had a fractured jaw?*
  • Do you have any issues with jaw pain/TMJ/TMD?*
  • Do you need to be pre-medicated before dental treatment?*
  • Do you currently have cavities/toothaches that need treatment?
  • Any Clicking/ Popping or Jaw pain?
  • Do you grind or clench your teeth day or night?
  • Ever injured any teeth?
  • Ever injured jaws or face?
  • Do you need to be pre-medicated before dental treatment?
  • Realizing that successful treatment greatly depends upon your cooperation in following instructions, keeping appointments, and maintaining oral hygiene. Are there any restriction, handicaps, or problems that might be encountered during treatment?**
  • Have had tonsils/adenoids removed?

  • Insurance

    *Insurance is not required
  • Do you have Dental insurance?*
  • Policy Holder Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Take a photo of the front of your insurance card:
  • Take a photo of the back of your insurance card:

  • If there is dual coverage or another dental plan, please complete the following section:

  • Is patient covered under another dental plan?
  • Policy Holder Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Take a photo of the front of your additional insurance card:
  • Take a photo of the back of your additional insurance card:

  • Signatures

  • Privacy Policy

  • SMS Disclosure

  • 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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