New Patient Form 

Welcome to our practice. To best serve you and make your first appointment as efficient as possible, we ask that you fill out all of the following information as completely as possible. We are looking forward to meeting you!!


Birth Date





We have found that the best way to stay in contact is through texting – You can text us at any time using our office number (865-522-0121)





Policy Holder Birth Date


Policy Holder Birth Date


Have you visited an orthodontist before?

Please rate the patient's oral health:

Do you have regular dental check-ups?

When was the last check-up?

Do you clinch/grind your teeth?

Do you have pain/tenderness/clicking in your jaw joint (TMJ), frequent headaches?

Do you have any of the following habits? (Select all that apply)



Please rate your overall health:

Are you currently being treated by a physician?

Have you ever experienced the following medical conditions? (Check any that apply)

Are you currently Pregnant or Nursing?


I understand that the information provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is MY responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payments of any benefits to the office of Langford Orthodontics. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE (FOR ANY REASON).

Signature of Patient/Responsible Party:

** We have found that the best way to communicate with our patients is through email or texting. You may text us at any time by using our office number (865-522-0121). We are often able to communicate with you more efficiently through texting – without interfering with your day.

May we text information about patient appointments, treatment, and financial status to the Cell Phone number provided?

Signature giving OK to text information :