Patient Information

Patient's Full Name *

Date of birth *

Gender *

Male
Female
Non-binary / Other
Prefer not to say
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Is patient 18 years old or over? *

Yes, patient is 18 years old or older.

No, patient is under 18

Phone

Email

Address

Street Address *

City

State

Postal code

Primary Responsible Party

Primary Responsible Party (Full Name) *

Relationship to Patient - Primary *

Phone Number - Primary *

Email - Primary *

Text

Secondary Responsible Party (Full Name)

Relationship to Patient - Secondary

Phone Number - Secondary

Email - Secondary

Primary Insurance Information

Name of Insurance Company

Insurance Phone Number

Subscriber's Name

Subscriber's Date of Birth

Insurance Member ID # or Subscriber SSN#

Secondary Insurance Information (Optional)

Name of Insurance Company - Secondary

Insurance Phone Number - Secondary

Subscriber's Name - Secondary

Subscriber's Date of Birth - Secondary

Insurance Member ID # or Subscriber SSN# - Secondary

Additional Information

Medical History That We Should Know About *

How Did You Hear About Us? *

Search Engine (Google, Bing)
Online Ad (Google, Facebook)
Doctor or Friend Referral
Sign or Billboard
Print (Flyer, Mail, Newspaper)
Other
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What Brings You Here? What Concerns Do you Have With Your Teeth? *

Is there a history of thumb or finger habit?

Yes

No

Do You Prefer Braces or Aligners? *

Braces

Aligners

Do You Have Any Reservations With Starting Orthodontic Treatment? *

Yes

No

If Yes, Why? What Are Your Concerns?

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