Welcome
Patient Forms
Our Office
Our Doctors
Office Tour
Our Team
About Orthodontics
Orthodontics in Children & Adults
Treatment Options
Financial
Smile Assessment
Your First Visit
New Patient Form
Doctor Referral Form
Community
Sponsorships
Vivid Bucks
Contact
Patient Login
Welcome
Patient Forms
Our Office
Our Doctors
Office Tour
Our Team
About Orthodontics
Orthodontics in Children & Adults
Treatment Options
Financial
Smile Assessment
Your First Visit
New Patient Form
Doctor Referral Form
Community
Sponsorships
Vivid Bucks
Contact
Patient Login
Smile Assessment
Your First Visit
New Patient Form
Doctor Referral Form
New Patient Form
Please fill out the information to the best of your knowledge. We will contact you within 2 business days to set up a consultation appointment and to confirm any additional information that may be required before your first visit.
Name
*
First Name
Last Name
Patient Name (If different than above)
If you are a parent booking an appointment on behalf of your child, please indicate their name.
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Preferred Days (Mon-Fri)
Reason for requesting consultation
Crowding
Spacing
Issues with bite
Dentist recommendation
Other (please fill us in below)
Message (please let us know if there is anything that you would like us to be aware of contacting you)
How did you hear about our practice?
Dentist Referral
Friend
Online
Staff Member
Other
Thank you!
