• Adult New Patient Form

  • Patient Information

  •  -  -
    Pick a Date
  • Dental Insurance Information

    (If you have it)
  •  -  -
    Pick a Date
  • Secondary Dental Insurance

    (If you have it)
  •  -  -
    Pick a Date
  • Medical Insurance

  •  -  -
    Pick a Date
  • Motivation for Treatment: The Teeth

    If your teeth could be changed, how would you like them to change?
  • The Face

    If your facial appearance could be changed, what would you change?
  • Symptoms

    If you want to reduce pain or discomfort where is it located? Please be specific about the location; select right side, left side or both if they apply.
  • Dental Information

    Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment your you receive from our office. This information is kept strictly confidential.
  • Medical Information

  • Medical History

  • Privacy Notice

  • Insurance Release and Agreement

    I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. I understand that I am responsible for payment of services rendered as well as any co-payments or deductibles.
  • Clear
  •  -  -
    Pick a Date
  • Signature/Verification of Information

    I hereby state that I have read, understand and have truthfully, to the best of my ability answered all questions containted on this form. I will not hold my Orthodontist or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my Orthodontist of any changes in medical or dental health. I authorize the Orthodontist or their staff to perform any necessary dental services that I may need. I authorize this practice to share treatment with collaborating dentists, surgeons, or other professionals when appropriate.
  • Clear
  • Click submit to securely send this form to our practice.Please note that further signatures may be required in the office.
  • Should be Empty: