New Patient Form

Responsible Party


Health History

Please Check All That Apply
Please Check All That Apply

What's Most Important to You?

We consider your satisfaction to be of utmost importance, and this starts by personalizing your orthodontic experience. Please review the treatment aspects below that our skilled team of professionals can deliver using several state-of-the-art technologies.
(Please rank your top three treatment aspects from 1 to 3)

Orthodontic Insurance Information

By signing below I understand that the information I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes.
In the separation/divorce situations, the individual who initiates services with us is held financially responsible. We do not bill another person or an estranged spouse unless that individual informs us in writing of his or her willingness to pay for services. We will assist you in filing your insurance. Services rendered are charged to the patient, not the insurance company, and patients are expected to take care of their fees as services are rendered unless special arrangements have been made.
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