Are you an existing patient?
Please select location you would like to visit?
*First Name:
*Last Name:
*Gender:
Social Security #:
*DOB:
*Home Address:
*City:
*State:
*Zip:
*Cell Phone:
Home Phone:
*Email:

Whom may we thank for referring you?
Who is your dentist?
Phone number of your dentist:
Date of last dental visit:

What type of treatment are you most interested in?
Have you ever had an orthodontic consultation or treatment before?
If yes, when and where:

Are you taking any medication?
Do you have any allergies?
Major illness:
Operations:
Accidents:
Abnormal Bleeding/Hemophilia
Anemia
Arthritis
Asthma/Hayfever
Bone Disorders
Congenital Heart Defect
Diabetes
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/AIDS
Kidney Problems
Nervous Disorders
Pneumonia
Radiation/Chemotherapy
Tuberculosis
Cancer
Other Conditions
Apprehensive about dental care
Presently in dental pain
Unfavorable reaction to dentistry
Missing or extra permanent teeth
Injury to face, jaw, teeth, or mouth
Bleeding gums
Oral habits
Mouth breathing
Discomfort from teeth or gums
Pain, tenderness, or noise in either jaw
Grind or clench teeth
Frequent sore throats
Speech problems/therapy
Snores during sleep
Frequent headaches
Neck/shoulder pain
Brush daily
Floss daily
Fluoride treatments
Frequently chews gum
Requires premedication
Pregnant
Menstruation started
First Name:
Last Name:
DOB:
SSN:
*Home Address:
*City:
*State:
*Zip:
*Cell Phone:
Home Phone:
*Email:

First Name:
Last Name:
DOB:
SSN:
*Home Address:
*City:
*State:
*Zip:
*Cell Phone:
Home Phone:
*Email:
Dental Insurance Company Name:
Subscriber's Name:
Subscriber's ID/SS#:
Subscriber's D.O.B.:
Employer:
Relationship to patient:

Any Alternative (secondary) Insurance Company:
Subscriber's Name:
Subscriber's ID/SS#:
Subscriber's D.O.B.:
Employer:
Relationship to patient: