Adult Registration Read Our Reviews Patient Information* RequiredPatient's Name*Preferred NameGender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY AgeAddress* Street Address Home PhoneCell PhoneFor appointment reminders, who is your cell carrier?Email HobbiesEmployer InformationEmployerOccupationWork PhoneMarital StatusSingleMarriedDivorcedOtherSpouse's NameSpouse's Cell PhoneDentist Full NameWho referred you to us?Dental Insurance InformationPolicy Owner's NameRelationship to PatientPolicy Owner's DOB Date Format: MM slash DD slash YYYY Member ID or SSNPolicy Owner's EmployerInsurance CompanyGroup #Insurance Co. PhoneInsurance Co. Address Street Address Medical and Dental HistoryAre you currently under the care of a physician or anything about your health history that we should be aware of?*YesNoIf yes, please explainPhysician's NamePhysician's PhoneCurrent medications and reason for taking:AllergiesAre you currently pregnant?YesNoHave you had your tonsils or adenoids removed?YesNoHave you had any injuries to you head or mouth?YesNoIf yes, please explain injuriesDo you have any jaw joint (TMD/TMJ) pain or discomfort?YesNoDo you have missing or extra teeth?YesNoDo you have a speech problem or tongue thrust?YesNoDo your gums bleed?YesNoDo you visit your dentist regularly?YesNoDo you use tobacco products?YesNoDo you like your smile?YesNoWhat are your chief concerns about your teeth?Are you interested in?BracesInvisalign®BothHave you been evaluated by another orthodontist?YesNoSignatureSignature*Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
