Orthodontic Intake Form

Thank you for considering our office for your orthodontic needs; we assure you that you’ve made an excellent decision! This form is for new Braces and Invisalign Consultations only.

Before your first visit, we request that you complete the following form. By completing this information before your scheduled visit, we can dedicate more time to your needs and introduce you to our incredible team members!

If you have any questions while filling out this information, don’t hesitate to call our office! We are always happy to help.

First name *

Last name *

Phone Number *

Email *

Address *

Preferred Language *

Where did you hear about us? *

Insured's Name: *

Insured's Date of Birth *

Insured's Social Security #

Relationship to Patient *

Insurance Company

Group #:

Member #:

Does your employer provide a flexible spending account (FSA)?

Do you currently have or have had any medical problems? *

If so, which?

Do you have any allergies? *

If so, which?

Are you taking any medications? *

If so, which?

Have you had any operations? *

If so, which?

Have you ever been involved in a serious accident? *

If so, explain:

Female Patients: Are you pregnant or plan on becoming pregnant?

Primary Dentist: *

Date of Last Visit:

Have there been any injuries to the face, mouth, or teeth? *

Any type of finger sucking or tongue habit? *

Is the patient a mouth breather? *

Do you ever have any jaw joint pain? *

Tooth grinding or clenching? *

Any speech problems? *

Have you ever had braces or other orthodontic treatment before? *

Have you had a recent orthodontic consultation? *

If so, with whom and when?

Are you willing to start treatment today if there is room in the schedule? *

Do you have a preferred treatment option in mind? *

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By providing a mobile number or email address, I agree that Miller Pediatric Dentistry and Orthodontics may send automated appointment and dental marketing messages at the number and email I provided above. *

I agree

I understand that my (or my child's) diagnostic records may be used for educational purposes. I have truthfully answered all the above questions and agree to inform the office of any changes to my medical or dental history. *

I agree