Patient Information

Patient's Full Name *

Date of birth *

Gender *

Is patient 18 years old or over? *

Yes, patient is 18 years old or older.

No, patient is under 18

Address

Street Address *

City

State

Postal code

Primary Responsible Party Information

Full Legal Name - Primary *

Preferred Name (Optional) - Primary

Phone Number - Primary *

Email - Primary *

Relationship to Patient - Primary *

If Other Please Specify

Professional Title or Credential (Optional) - Primary

Secondary Responsible Party Information

Full Legal Name - Secondary

Preferred Name (Optional) - Secondary

Phone Number - Secondary

Email - Secondary

Relationship to Patient - Secondary

If Other Please Specify - Secondary

Professional Title or Credential (Optional) - 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? *

What Brings You Here? What Concerns Do you Have With Your Teeth? *

Is there a history of thumb or finger habit?

Yes

Do You Prefer Braces or Aligners? *

Braces

Aligners

Do You Have Any Reservations With Starting Orthodontic Treatment? *

Yes

If Yes, Why? What Are Your Concerns?

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