New Patient Form
Gender* MaleFemaleOtherPrefer not to say
Date of Birth*
Do you or have you ever had any of the following medical conditions?*
No allergies, no medical condition, no medicationsAllergiesAsthmaBleeding disorderBlood pressure problemsDiabetesEating disordersEpilepsyHeart diseaseImmunosupressionMedicationsother
Have you ever had an accident involving your teeth or jaws?* YesNo
Treatment Preference
BracesClear alignersNo preferenceOther
How soon would you like to start orthodontic treatment?ASAP6+ monthsOrthodontist’s recommendation
Parent/Guardian Details (if patient is under 18 years, please provide details of the persons financially responsible for this patient).
