• Adult New Patient Form

  • We would like to welcome you and your child to our office. Our goal is to make everyone's visit pleasant, stress-free and educational. We pride ourselves in creating beautiful smiles that lasts a lifetime. We look forward to seeing you in the office.

  • Information Must Be Filled Out Completely

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  • Employer Information

  • Spouse Information

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  • Person Responsible for Account

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  • Primary Orthodontic Insurance

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  • Secondary Orthodontic Insurance

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  • Medical History

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  • For Women
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  • What are the main concerns you and/or your dentist would like orthodontics to address?

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  • Please list an emergency contact not living with you
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  • Agree to Terms

    I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    **You May Refuse to Sign This Acknowledgement**
  • Click Here To Review Form

  • I ________________________ , have received a copy of this office's Notice of Privacy Practices.

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