Child Health History

To Our New Patients:

Your kindness in furnishing the following information will be appreciated in preparing your child’s clinical chart.


Does your child have or has he/she had any of the following:

Is your child allergic to or has he/she had any unusual reactions to:

Child Dental History

I give my consent for the initial examination at no charge. If diagnostic records are needed to determine the necessity of orthodontic treatment, I give my consent and accept responsibility for payment of records which will include x-rays, study models and photographs

If printing form, please remember to bring completed form with you to your first visit.

we offer invisalign