Adult Registration Form
* required field

Patient Information

Gender





Primary Phone Number
Secondary Phone Number


Spouse/Emergency Contact Information

Marital Status







Insurance Information






















Dental History


How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?

Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Have you ever had an injury to (select all that apply):
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?


Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you had any serious illnesses or operations? If yes, describe:
(Women)




Check if you have or have ever had any of the following:

Authorization




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