Download Printable Version

New Patient Form

How did you hear about us?

Responsible Party Information

Insurance Information

Patient Health History

Speech therapy/problems
Clinching or grinding of teeth
Missing or extra permanent teeth
Oral habits (thumb sucking, lip or nail biting, or extended pacifier use)
Injury to face, jaw, teeth, or mouth
Teeth sensitive to hot or cold temperatures
Jaw clicking, locking, pain or tenderness
Previous root canal therapy
Heart murmur
Heart attack or stroke
Hypertension/high blood pressure
Received radiation therapy
Bone loss / bone disorders
Seizures/epilepsy/neurological disease
Taken bisphosphonates (Fosamax, Actonel, Boniva, etc.)
Autism or social/pyschological issues
Allergy to latex
Metal allergy or allergy to ear rings
Significant dental or medical history not noted above

Emergency Contact

I acknowledge that I have completed this from to the best of my ability and the information is true. I will not hold my orthodontist or any member of the staff responsible for omissions or errors that I may have made during the completion of this form. If there are any changes to this medical record, I understand that I must provide the information to the office in a reasonable time frame (within 30 calendar days)
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.