If the patient is a minor, 18 or younger : Go to Child Form

    Patient’s Information:

    First Name:*

    Last Name:*



    Date of Birth:*




    Postal code:*


    Phone Number 1:*

    Phone Number 2:

    How did you hear about our office?*


    If you checked dentist, please specify:

    If you checked other, please specify:

    Dental Insurance

    Do you have DENTAL INSURANCE that covers orthodontic treatment?

    Our office will try to get your coverage information in advance for you with your permission:

    Name of the plan holder:

    Relationship to the plan holder:

    Insurance company:

    Plan holder's Date of Birth (YYYY-MM-DD):

    Subscriber ID/Certificate Number:

    Group/Policy Number:


    Dental / Medical History

    Are you in good general health? YesNo

    When was your last visit to a family doctor?

    How long ago was your last visit to a dentist?

    Have you had any serious chronic illnesses or operations? YesNo

    If yes, please specify

    Do you require pre-medication before dental work? YesNo

    If yes, what condition is that for?

    Are you taking any medications? YesNo

    If yes, please list:

    Do you have a history of (please click all that apply):Heart problemsAllergiesDiabetesAsthmaFaintingArthritisHepatitisRheumatic feverSnoringMouth breathing

    Do you have a history of (please click all that apply):Difficulty opening the mouth'Popping' or 'Clicking' noises from the jaw jointsPain around the ears or cheekPain on opening wide, chewing or yawningLocked or dislocated jaw

    Have you ever had injury to (please click all that apply):The JawTeethMouthHeadNeck

    Does your bite feel uncomfortable or unusual? YesNo

    Have you been treated for TMJ (Temporomandibular disorder)? YesNo

    Are you under any stress? YesNo

    Is there any other health information that we should know about? YesNo

    If yes, please explain:

    Have you had any previous orthodontic treatment? YesNo

    If yes, please explain:

    Have you consulted with another orthodontist? YesNo

    If yes, please explain:

    When was the last radiographs taken? (Panoramic X-ray, if there is any):