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We would like to welcome you and your child to our office. Our goal is to make every child's/patient's visit pleasant and educational. We strive to teach good oral care that will enable our patient's to have a beautiful smile that lasts a lifetime.
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Do you have orthodontic insurance?YESNO
Is the Patient concerned about their teeth?YesNo
Has Patient had previous treatment forGum DiseaseTMJ
Any previous orthodontics treatment?NoYes
Is this second opinion?NoYes
Are they satisfied with the end results?NoYes
Is the Patient frightened or anxious about treatment?NoYes
Does the patient have any speech problemsNoYes
Any injuries to face, head, mouth or teeth?NoYes
Pain in or near ears?NoYes
Clicking or locking of jaws?NoYes
Headaches, facial pain or jaw joint problems?NoYes
Please rate patient's oral hygiene:FairGoodPoor
Does patient brush teeth daily?NoYes
Does patient floss teeth daily?NoYes
Overall medical healthPoorFairGood
Have tonsils and adenoids been removed?NoYes
Is premeditation needed before dental treatments?NoYes