Orthodontic New Patient Acquaintance Form

In this section are confidential forms that area very important. Please take the necessary time to accurately fill them out.

We suggest that this be done when you are not rushed and can candidly reveal any concerns regarding the patient's orthodontic care. The more we know about him or her, the better we'll be able to serve you.

Please submit this form digitally as soon as possible, and at minimum 48 hours prior to your appointment.

MEDICAL INFORMATION
DENTAL INFORMATION
GENERAL INFORMATION
DENTAL INSURANCE
**Please note that we file insurance for the primary carrier only**
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any change‚Äôs in the patient's medical status. I authorize the dental staff to perform the dental services the patient may need.