ONLINE NEW PATIENT FORM

We are an orthodontic office! We work with braces and clear aligners to bring new smiles to our patients! We are not a general dentist. We do not complete cleanings, extractions, cavities, root canals, etc.

Yes! I am interested in braces and/or clear aligners. *

Although we do not work with State Insurance / Husky / Medicaid, we do offer flexible in-house financing for monthly payment options!

Patient Information

Patient First Name *

Patient Last Name *

Patient Nickname *

Patient Date of Birth *

If the patient is a minor

Cellphone Number *

Email Address *

Mailing Address *

How did you hear about our office? *

Who is the patient's regular dentist? *

What are the main concerns for the patient to visit our office? *

We treat children and adults! Is there anyone else in the family you'd like to bring in for a complimentary consultation? The American Association of Orthodontics (AAO) recommends children age 7 or above should be seen by evaluated by an orthodontist.

To help streamline the patient's consultation, we can provide a complimentary dental insurance check to discuss any benefits available. (We do not work with State Insurance / Husky / Medicaid).

INSURANCE (PRIMARY)

INSURANCE (SECONDARY)

ONLINE NEW PATIENT FORM

Patient Information

To help streamline the patient's consultation, we can provide a complimentary dental insurance check to discuss any benefits available. (We do not work with State Insurance / Husky / Medicaid).

Thank you!