New Patient Form - Minor (under 18)

Please complete the new patient form prior to your visit. If you are unable to complete the form beforehand, please arrive 10 minutes before your scheduled appointment to complete. We do our best to stay on schedule!

Patient's Name

First Name

Last Name

Date of Birth

MM/DD/YYYY

Home Address

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

School & Grade

Parent/Caregiver - Filling Out Questionnaire

First Name

Last Name

Relationship to Patient

Parent/Caregiver - Email

Parent/Caregiver - Cell Phone

(###)

###

####

Parent/Caregiver (Secondary)

First Name

Last Name

Relationship to Patient

Parent/Caregiver (Secondary) - Email

Parent/Caregiver (Secondary) - Cell Phone

(###)

###

####

What motivated you to seek orthodontic treatment?

Select all that apply

Dissatisfaction with Smile Appearance

Crowded / Crooked Teeth

Spaced / Missing Teeth

Protruding Teeth or Lips

Open Bite / Overbite / Underbite / Crossbite

Jaw Pain / Jaw Joint Problem

Small / Large Jaw

Facial Growth Disharmony

Has anyone in the family had orthodontic treatment? If so, by whom?

Patient's Dentist Name

Do you have insurance coverage for orthodontic treatment?

If yes, please select provider:

Membership Number

Group Number

Please let us know who referred you to our office, so we may thank them!

Is there anything else you'd like Dr. Wall and his staff to know that wasn't covered above?

This information is confidential and is correct to the best of my knowledge. It is my responsibility to inform this office of any changes in medical status. I authorize Dr. Michael J. Wall and his staff to perform necesary dental services with my informed consent that are needed during diagnosis and treatment.

By checking the below box, you confirm that you have read the above statement before submitting this form.

Agree