• Adolescent 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.

  • TELL US ABOUT YOUR CHILD

  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Mother's Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does Mother have legal custody of this child?

  • Father's Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does Father have legal custody of this child?

  • 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
  • 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?*

  • PARENTS’ MARITAL STATUS

  • Please place a check by the appropriate answer
  • Who will be responsible for the bill?
  • If both, will it be equal responsibility?

  • Patients's Medical History

  • Is your child taking any medications (include over-the counter)?
  • Current Health is:

  • Does patient have a history of any of the following?

    Or select "None" if no history of any of these conditions
  • Medical History*
  • 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**
  • Vision/Hearing**
  • Have adenoid and/or tonsils been removed?
  • In order to gauge growth, has puberty begun?
  • Girls: Has menstruation begun?

  • Is your child allergic to any of the following?

    Or select "None" if no allergies
  • Allergies*
  • Anesthetics**
  • Aspirin**
  • Amoxicillin**
  • Codeine**
  • Cyclosporins**
  • Erythromycin**
  • Latex**
  • Metal**
  • Penicillin**
  • Sulfa Drugs**
  • Tetracycline**

  • Patient's Dental History

  • Are there any outstanding general dental needs (fillings, crowns, etc.) at this time?*
  • Date of last dental visit:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has patient had previous orthodontic treatment?*
  • Has patient had problems or complications with previous dental treatment?*
  • Have there been any injuries or trauma to the face, mouth, teeth or chin?*
  • Have you ever had a fractured jaw?*
  • Does patient have any oral habits (finger/thumb sucking, tongue thrust)?*
  • Does patient have any issues with jaw pain/TMJ/TMD?*
  • Does patient need to be pre-medicated before dental treatment?**
  • Has anyone in the patient's family had jaw surgery or have an underbite?
  • Has patient been treated by a periodontist?
  • Does patient use any type of flouride products?
  • Does patient grind or clench teeth day or night?
  • Has patient had tonsils/adenoids removed?
  • 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?**
  • Inherited any family or dental problems?
  • Ever injured any teeth?
  • Ever injured jaws or face?

  • PATIENT'S DENTAL HISTORY

  • Have you ever had complications following dental treatment?
  • Do you currently have cavities/toothaches that need treatment?
  • Any Clicking/ Popping or Jaw pain?
  • Do you need to be pre-medicated before dental treatment?

  • 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

  • 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!

  • Take a photo of the back of your additional insurance card:
  • Should be Empty: