Skip to the content
Please enable JavaScript in your browser to complete this form.
Patient Name
*
First
Last
Birthday
*
Please provide patients date of birth MM/DD/YYYY
Relationship to Patient
*
Self
This is my Child
Other
Name of person responsible for the patient
*
First
Last
Cell Phone #
*
Email - What's the best email to send new patient forms?
*
You will receive an email to complete all necessary forms prior to your scheduled appointment.
Do you have Dental Insurance?
*
Yes
No
We MUST receive this information in order to verify any ORTHODONTIC coverage.
Insurance Information
I prefer to take a picture of my Dental Insurance card to upload now
I will provide insurance information later
If you have more than one insurance, we will gather this information during the next steps
Insurance Card Upload
Click or drag a file to this area to upload.
Take a picture of the front of your dental insurance card to upload to us. We can then verify your benefit.
Comments
Is there anything specific you would like us to know?
Submit