Patient Name
*
First Name
Last Name
Is this patient a minor
*
YES
NO
Parent/Guardian Name
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referred By
*
First Name
Last Name
Practice Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office Email
*
example@example.com
Choose areas of concern for the patient:
*
Underbite
Deep Bite
Open Bite
Crossbite
Spacing
Crowding
Protrusion
Eruption/Impaction
Phase I Treatment (ages 7 and up)
Date of Last Cleaning
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Next cleaning scheduled?
*
YES
NO
Date of Next Cleaning
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is there any pending dental work?
*
Yes
No
If yes, please list dental work:
Periodontal Condition of Patient
*
Good
Fair
Poor
Date of Last Panoramic X-Ray
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Panoramic X-Ray and Periodontal Chart (if available)
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Please upload panoramic x-ray and periodontal chart, or email to records@dochollidaybraces.com.
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