Patient Registration

Save time on your visit by filling out your health history below. (* Required field)

Patient Information
Preferred method of contact (check all that apply)
Have you seen an orthodontist before?
Have you ever received orthodontic treatment?
1 of 7
Responsible Party
2 of 7
Emergency Contact
3 of 7
Medical History
All information gathered will be held in the strictest confidence. We require this information in order to completely understand your overall health which may impact your orthodontic treatment. Please fill out this section as accurately as possible.
Does the patient have any allergies?
Is the patient currently taking any medications?
Does the patient currently have, or has had in the last 2 years any medical condition?
Has the patient been hospitalized for a serious illness?
Does the patient have a history of any major operations?
Please check all that apply:
4 of 7
Dental History
Check all that apply
5 of 7
Insurance Information
Although we do not take assignment of insurance, as a courtesy to our patients we will assist them in obtaining and filing out the forms necessary for reimbursement from your insurance provider.
Do you have additional insurance policy to add
6 of 7
Consent

I consent to giving permission to Design Orthodontics for conducting an orthondontic exam and obtaining any orthodontic records that are deemed necessary and relevant in the diagnosis and treatment planning of my case. I consent to giving permission to Design Orthodontics to release any information concerning the dental and orthodontics health to the patient’s family dentist, physician and any other dental specialist that may be involved in the treatment of my case.

7 of 7