Patient Information

Responsible Party Information

(*If the patient is a minor, this is the main parent or guardian who will be bringing the patient to the appointments and who is legally eligible to make decisions for the patient.)

no yes

  If No, please complete the following information:

Dental Insurance Information

no yes

  If Yes, please complete the following Secondary Insurance information:

Medical History

Please fill out this section as completely as possible. It is important for us to be aware of any health issues that may affect orthodontic treatment. If the Patient is a Minor, the Responsible Party should fill out this section. We will keep all information strictly confidential.
no yes
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no yes

Please check any of the following which apply to you, and add any relevant comments:
no yes
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Dental History

no yes
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Security Captcha

or

If printing form, please remember to bring completed form with you to your first visit.