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ORTHO 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.

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Preferred Language *

Where did you hear about us? *

Insured's Name *

Insured's Date of Birth *

Relationship to Patient *

Insured's Social Security #

Insurance Company

Group #:

Member #:

Does your employer provide a flexible spending account (FSA)

Yes
No
Unsure

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

Yes
No

If so, which?

Are you taking any medications? *

Yes
No

If so, which?

Do you have any allergies? *

Yes
No

If so, which:

Have you had any operations? *

Yes
No

If so, which:

Have you ever been involved in a serious accident? *

Yes
No

If so, explain:

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

Yes
No

Primary Dentist: *

Date of Last Visit *

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

Yes
No

Any type of finger sucking or tongue habit? *

Yes
No

Is the patient a mouth breather? *

Yes
No

Do you ever have any jaw joint pain? *

Yes
No

Tooth grinding or clenching? *

Yes
No

Any speech problems? *

Yes
No

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

Yes
No

Have you had a recent orthodontic consultation? *

Yes
No

If so, with whom and when?

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

Yes
No

Do you have a preferred treatment option in mind? *

Braces
Clear Braces
Invisalign
Unsure

By providing a mobile number or email address, I agree that Children's Dentistry of Coral Springs 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

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954-344-0445
8150 Royal Palm Blvd #104
Coral Springs, FL 33065
Mon - Fri: 8AM - 5PM

Services

Infant oral care
Preventative Care
Restorative dentistry
Emergency dentistry
Special needs dentistry
Early treatment for children
Braces for kids teens adults
Invisalign for kids teens adults

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