Welcome

to the

Orthodontist

We would like to welcome you and your child to our office.  Our goal is to make every child's visit pleasant and educatiional.  We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

Tell Us About Your Child

Parents Information

Today's Date:

Child's Name:

Last       First        MI

Nickname:

Childs Birthdate:

School

Hobbies/Sports:

Child's Home Phone #:

Childs Cell Phone #

Child's Home Address:

List Brothers/Sisters with Birthdates

Family Dentist:

Last visit date:

Other Family Members seen by us:

Whom may we thank for telling you about our office?

Mother''s name:

Address:

Work #

Home #

Occupation:

Employed by:

How long there:

S.S.#

MOTHER'S INFORMATION

Father's name:

Address:

Work #

Home #

Occupation:

Employed by:

How long there:

S.S.#

FATHER'S INFORMATION

Cell #

Email:

Cell #

Email address:

Person Responsible for Account

Name:

Relation

Billing Address:

Wk.#

Home #

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