Fill out your dental health history form online.

For new patients only

Please fill out the form, then go to the Appointments section to schedule your first appointment.

Patient:

Date:

First Name: MI: Last Name:

Address:

Suite/Apt #

City: State: Zip Code:

D.O.B: SS# - -

Phone Number: ( ) -

E-Mail Address:

Marital Status:

Responsible Party:

First Name: MI: Last Name:

Address:

Suite/Apt #

City: State: Zip Code:

Phone Number: ( ) - SS# - -

Relation: Employer:

Business Address:

Work Phone: ( ) -

Insurance: Referred:

Why Do You Want to See An Orthodontist?:

Please Check All That Apply:

Had Orthodontic Treatment Before Want to Improve My Smile Have Crooked Teeth Have Missing Teeth Have Protruding Teeth Have Deep Bite Do Mouth Breathing Do Clenching or Grinding Do Brush Daily Use Dental Floss Use Inter Dental Stimulators Use Water Jet Device

Please Check All That Apply:

Have Heart Ailments

Have Anemia/Blood Problems

Have Arthritis

Have Asthma

Have Immune System Disorders

Have Eye Disorders

Have Tonsilitis

Pregnancy if so Month:

Describe Any Current Medical Treatment:

INSURANCE: We do all the insurance filing for you: insurance information is needed to obtain all your benefits.

You should know that Orthodontic coverage usually pays only a part of the fee.

Our office is here to help you with your insurance needs and obtaining all your benefits. Misunderstandings can occur regarding Orthodontic coverage. Patients should know that the total fee is charged to the patient's account. The patient is responsible for payments not paid by insurance benefits, due to cancellations, change of employment, etc.

Click Here To Make An Appointment