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Treatment Options
Children's Orthodontics
Teen Orthodontics
Adult Orthodontics
Aligners
Advanced Metal Braces
Aesthetic Braces
Surgical Orthodontics
Cleft Lip & Palate / Craniofacial Care
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Locations
Colorado Springs
Woodland Park
Patient Resources
Cost of Orthodontics
Insurance Information
Patient Forms
Contact
New Patient Evaluation Form
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New Patient Evaluation Form
Patient Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
Other
*
Address:
*
City:
*
State:
*
Zip:
*
Main Phone:
*
2nd/Cell Phone:
*
Email:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
*
First Name:
MI:
*
Last Name:
*
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
*
Main Phone:
*
Email:
*
Address:
*
City:
*
State:
*
Zip:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the insurance company
Employer:
Occupation:
Length of Employment:
Do you participate in a flexible savings plan?
No
Yes
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Have you had a previous orthodontic consult or treatment?
No
Yes
If so, when?
What is your primary orthodontic concern?
Do you have any allergies or chronic health problems?
No
Yes
If yes, please explain:
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