• O-M-I Orthodontics

    Online Information Submission: Welcome To Our Practice!

    Because your time is very valuable we continually change our procedures to honor your time with us, this system was developed to save you time on the phone and at our office. Please complete the following registration and health history below online! It takes but a few minutes from the comfort of your home to fill out this confidential form where you have access to all your important information. When completed, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.

  • Patient Information:
    (Section 1 of 6)

    Items marked with asterisk (*) must be completed.

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  • Whom may we thank for referring you to our office? (Our best patients come from referrals and we want

  • Responsible Party Information:
    (Section 2 of 6)

    Items marked with asterisk (*) must be completed.

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  • Dental Insurance Information:
    (Section 3 of 6)

    Items marked with asterisk (*) must be completed.

  • Emergency Information:
    (Section 4 of 6)

    Items marked with asterisk (*) must be completed.

  • Medical History:
    (Section 5 of 6)

    Items marked with asterisk (*) must be completed.

    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 you receive from our office. This information is kept strictly confidential.

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  • Dental History:
    (Section 6 of 6)

    Items marked with asterisk (*) must be completed.

    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 you receive from our office. This information is kept strictly confidential.

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    Pick a Date
  • Please check any of the following which apply to you.

    add any relevant comments.
  • By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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