New Patient Form

Please fill out this form online and submit it at the bottom of the page. Or you can download a PDF , print it, fill it out, and bring it to your first visit.

Patient Information

Lastname
Firstname
Middlename
Nickname
Title:
Prefix:
Gender:
Address
City, State, Zip
Home
Birthdate
Age
Dentist Name
Physician Name
Who referred you to us?

FOR ADULT PATIENTS ONLY

Work
Cell
Employer
SSN

Parent / Guardian Information

For patients under age 21, or spouse for adult patients

Responsible Party 1:

Lastname
Firstname
Middlename
Nickname
Title:
Prefix:
Gender:
SSN
Birthdate
Age
Address
City, State, Zip
Home
Work
Cell
Employer
Relationship

Responsible Party 2:

Lastname
Firstname
Middlename
Nickname
Title:
Prefix:
Gender:
SSN
Birthdate
Age
Address
City, State, Zip
Home
Work
Cell
Employer
Relationship

Insurance

Primary Orthodontic Insurance

Name of Insured
Insurance Company
Group Number
Lifetime max

Secondary Orthodontic Insurance

Name of Insured
Insurance Company
Group Number
Lifetime max

History

Medical History

Dental History

I verify that the above information is true to the best of my knowledge.

Initals
Date:

Updates

Medical / Dental History

Inform us of any future changes

Initals
Date:
Initals
Date:
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