New Patient Form

Fill out the New Patient Registration Form right here, then download it as a completed PDF to print, sign and bring to your first visit. Your answers stay on your own device: nothing you type is sent to us or stored online.

Prefer paper? Download the blank form (PDF).

Patient Information

Patient’s full name Age Date of birth Preferred name Home phone Cell phone Best method to reach you Email Home address City State Zip code Whom may we thank for referring you to our practice? Cell phone carrier (for text reminders)

Sex

M F

Appointment reminders by text message?

Yes No

Appointment reminders by email?

Yes No

If the Patient Is Under 18

Father’s name Father’s cell phone Mother’s name Mother’s cell phone School currently attending Grade

Responsible Party

First name Last name Date of birth Social Security # Email Primary phone Home address City State Zip code Employer Business phone Name of insurance company

Do you have insurance with orthodontic benefits?

Yes No

Dental / Medical Contacts

Family dentist Dentist phone Date of last exam Physician Physician phone Emergency contact name Relation Emergency phone

Medical and Dental History

Allergies Medications or drugs currently taking Need for antibiotic prophylaxis for a heart condition If you had a serious illness, operation or hospital stay in the past 5 years, please explain Main orthodontic concern

Latex and/or metal allergy

Latex Metal

Serious illness, operation or hospital stay in the past 5 years?

Yes No

Print Name and Date

Print name (patient or guardian)Date

Please sign the printed form by hand in the signature spaces before your visit.

Sunday	11am – 3pm
Monday	10am – 6pm
Tuesday	Closed
Wednesday	10am – 6pm
Thursday	11am – 7pm
Friday	10am – 2pm
Saturday	Closed

Patient Information

If the Patient Is Under 18

Responsible Party

Dental / Medical Contacts

Medical and Dental History

Medical History

Dental History

Print Name and Date