Want to breeze through your visit?
Fill this out now.

Totally optional. Knock it out now and you'll walk in and get right to the good part. Or skip it and we'll do it together on consult day, coffee in hand. Your call, no pressure.

Takes about 4 minutes. We promise to keep it painless.

Who's the star of the show?

The smile we'll be looking after.

Their full name

What do they like to be called?

They are…

Birthday

What's bringing you in?

No wrong answers here. Tell us in your own words.

What's bugging you about the smile (or what are you hoping for)?

Ever done the ortho thing before?

If yes, who and roughly when?

Who can we thank for sending you our way?

Who's in the crew?

So we know who to chat with and who's on chauffeur duty.

Parent / guardian #1, name

Their cell

Parent / guardian #2, name

Their cell

Who's bringing them to the visit?

Tag-team it? Will both grown-ups be at the consult?

If the parents live at different homes, anything we should know?

How do we reach you?

For appointment reminders and the occasional happy update.

Best email

Best phone

Home address

City

ZIP

Who's our main point of contact?

The grown-up paperwork

The slightly-less-fun-but-helpful part. Skip anything you don't have handy.

Want us to check your insurance before the visit?

Insurance carrier

Member ID

Group number

Name on the policy

Has all their regular dental work been done?

Who's your regular dentist?

Anything else on your mind?

Questions, worries, scheduling quirks, fun facts. We read every word.

Changed your mind? No worries at all. We'll have everything ready to go on consult day either way.