Patient Forms

    General Patient Information

    Responsible Party Information

    SingleMarriedSeperateDivorcedWidowed

    Dental Insurance Information

    Primary Insurance

    YesNo

    Secondary Insurance

    Emergency Information

    Medical/Dental History

    MaleFemale

    If patient is a Child

    Brothers and Sisters

    Each of the following questions must be checked YES or No, whichever correctly describes the PATIENT'S present or past health status

    Do you have any current or past health problems?
    YesNo
    Are you currently or were you previously under a physician's care for anything other than childhood disease?
    YesNo
    Have you ever been hospitalized ?
    YesNo
    Are there any medications being taken on a regular basis (including nonprescription)
    YesNo
    Are you allergic or sensitive to anything?
    YesNo
    Do you have or have you ever had any face, mouth, or teeth injuries?
    YesNo
    Why do you have difficulty breathing through your nose?
    YesNo
    Do you play a musical instrument with a mouthpiece?
    YesNo
    Have you had any previous orthodontic consultation or treatment?
    YesNo


    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
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    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    What concerns brought you to our office, and what changes would you like to see as a result of orthodontic treatment?

    Do you have any explanation or additional information about any disease,conditions, or problem not listed above that you think we should know about or see as a result of orthodontic treatment?

    We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.

    CONTACT US