Patient Information

First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Gender:

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Main Phone:
Address:
City:
State:
Zip:
Are there any other Family members that you would like us to evaluate?
Family members previously seen:
Whom may we thank for referring you to our practice?

Medical/Dental History

Primary Dentist:
Please list any medications currently being taken by the patient:

Please check all that apply
Have you had any additional consultations for braces?
Any other medical or dental concerns?

I give my permission for x-rays and photos to be taken:
The office may post my photos on Facebook for contests and before & after portfolio:

Patients Under 18

What school do you attend?
What grade are you in?
Are you excited about braces?
List Sports, Hobbies, Music:
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