• Patient's Information

  • Responsible Party's Information

    The Responsible Party is the person assuming financial responsibility for the treatment.
  • Please provide the following important information

  • In case we cannot contact/reach you:

  • Please answer the following questions

  • Please provide an outline of family dental/orthodontic history.

    This will assist in determining contribution of hereditary versus environmental factors in the cause of any orthodontic problem.
  • NameAgeAny problems with alignment of teethAny orthodontic treatment 
  • Any problems with alignment of teethAny orthodontic treatment
  • Any problems with alignment of teethAny orthodontic treatment
  • Patient Medical History

  • Have tonsils or adenoids been removed? If so, at what age?

  • Medical Records

  • THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS FORM AS FULLY AS POSSIBLE

    By submitting, you agree that you have completed this questionnaire to the best of your knowledge and understand that failure to make a full disclosure may place you at undue medical risk. You understand that notes, radiographs (x-rays) or models relating to your treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. You also give your permission for the practice to use the above contact details to send you appointment and checkup reminders.


  • ON FUTURE VISITS ANY CHANGES TO THE ABOVE SHOULD BE ADVISED


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After your form has been submitted a PDF of the content is generated and sent to our reception via our secure email platform. Immediately after the PDF is generated all parts of the form except the First, Middle and Last Name of the patient are encrypted in our database and erased after 24 hours.