Online Patient Health History Form
Submit Your Health History Form Online to Your Orthodontist
Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.
This website is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All of your personal health information is confidential, and will not be shared with anyone, aside from those involved in your treatment, without your consent.
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.