Orthodontics New Patient Form

Please complete the form below before your first visit

Is it ok to release appointment or medically related information concerning you?

How did you hear about us?

What are the main concerns you would like an orthodontist to accomplish?

Have you visited an orthodontist before? If so, when and why?

Do you have or have ever had any of the following? (select all that apply)

Have you ever had an injury to: (select all that apply)

Do you currently or have you ever had any of the following habits? (select all that apply)

Are you currently being treated by a physician? If yes, please include your physician's name, number, reason for treatment, and most recent treatment date.

Do you have any allergies or sensitivities to medications or latex? If yes, please list allergies.

Are you currently taking any prescription or over-the-counter medications? If yes, please list with dosage?

Have you had any serious illness or operations? If yes, please describe

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 my benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will beheld in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.
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Welcome New Patients!

Our goal is to make your first visit to our office as enjoyable as possible, and we would love to spend more time getting to know you and your family, and less time having you fill out paperwork. With that in mind, we have made it easy for you to fill out and submit the necessary paperwork electronically ahead of time. Please complete the appropriate Adult or Child New Patient Form, and then simply click the submit button at the bottom of the form.

NEW PATIENT FORM – ADULT NEW PATIENT FORM – CHILD

Orthodontics New Patient Form

Is it ok to release appointment or medically related information concerning you?

How did you hear about us?

What are the main concerns you would like an orthodontist to accomplish?

Have you visited an orthodontist before? If so, when and why?

Do you have or have ever had any of the following? (select all that apply)

Have you ever had an injury to: (select all that apply)

Do you currently or have you ever had any of the following habits? (select all that apply)

Are you currently being treated by a physician? If yes, please include your physician's name, number, reason for treatment, and most recent treatment date.

Do you have any allergies or sensitivities to medications or latex? If yes, please list allergies.

Are you currently taking any prescription or over-the-counter medications? If yes, please list with dosage?

Have you had any serious illness or operations? If yes, please describe

Welcome New Patients!

Call Today
440-449-5792

29001 Cedar Rd,
Lyndhurst, OH 44124

We’re welcoming new patients and can’t wait to meet you.

Company

Info

Orthodontics New Patient Form

Is it ok to release appointment or medically related information concerning you?

How did you hear about us?

What are the main concerns you would like an orthodontist to accomplish?

Have you visited an orthodontist before? If so, when and why?

Do you have or have ever had any of the following? (select all that apply)

Have you ever had an injury to: (select all that apply)

Do you currently or have you ever had any of the following habits? (select all that apply)

Are you currently being treated by a physician? If yes, please include your physician's name, number, reason for treatment, and most recent treatment date.

Do you have any allergies or sensitivities to medications or latex? If yes, please list allergies.

Are you currently taking any prescription or over-the-counter medications? If yes, please list with dosage?

Have you had any serious illness or operations? If yes, please describe

Welcome New Patients!

Call Today440-449-5792

29001 Cedar Rd, Lyndhurst, OH 44124

We’re welcoming new patients and can’t wait to meet you.

Company

Info

Call Today
440-449-5792

29001 Cedar Rd,
Lyndhurst, OH 44124