Adult Patient Form

We are really excited to meet you! How did you hear about us? (Select all that apply)

What are your chief concerns? (Select all that apply)

What type of treatment are you interested in?

Which METHOD of treatment are you most interested in?

What aspects of treatment are most important to you? (Select all that apply)

Date of birth?
 Cell Phone Carrier

 Approximate (or exact!) date of last dental cleaning and checkup

 Responsible Party Information

 Orthodontic Insurance Information

Policy Owner's Date of Birth


If yes, please fill out the following:
 Policy Owner's Date of Birth

 Have you ever had any of the following medical conditions?


 Have you had any of the following dental treatments?

Are you aware of any of the following dental problems?

 Have you ever had any of the following habits or special problems?

 I certify that the information provided on this form is correct to the best of my knowledge. I understand that it is my responsibility to report any changes.