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New Patient Form

Welcome! To ensure your first visit with us is quick, comfortable, and focused on your smile—not paperwork—we’ve made our new patient forms easy to complete ahead of time.

Fill out the form

Instructions

Your journey begins with a complimentary orthodontic consultation, where we’ll help you explore your options and create a personalized plan just for you. During this visit, you’ll:

  • Gather your personal, medical, and insurance details.
  • Decide whether you’d like to fill out the form online or download and print the PDF version.
  • Complete all required fields (*).
  • Review your answers – Double-check dates, contact information, and health details for accuracy before submitting
  • Submit online or bring the printed form to your appointment.
  • After submitting, you’ll receive a confirmation email or call from our team to finalize your visit details.
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Patient Information
2
Financial Party Information
3
Dental Insurance Information
4
Medical History
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Dental History
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Submit

Patient Information

Patient's Name

Address

Financially Responsible Party Information

Relationship to Patient

Dental Insurance Information

Emergency Contact Information

Medical History

Please check Yes or No

Is the patient in good health?

Please check Yes or No (If Yes, please fill in details)

Are you taking any medication?
Are you allergic to any medication?
Do you have a history of a major illness?
Have you had any major operations?
Have you ever been involved in a serious accident?
Please check any of the medical conditions below that you have had or currently have

Dental History

Please check Yes or No

Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth or teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist? If yes, who and when?
Would you object to wearing orthodontic appliances (braces) should they be indicated?
Has anyone in your family received orthodontic treatment?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have "tension" headaches?
Have you ever experienced chronic ringing in your ears?

Female Patients only

Are you pregnant?

Female Patients under age 18

Has menstruation started?

BENEFITS & ACKNOWLEDGMENT

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Fernando A. Vignolo to perform a complete orthodontic evaluation.

I have accepted the terms listed in the paragraph above *

Frequently asked questions

Got questions? We’ve got answers. Here’s everything you need to know to start your smile journey with confidence.

How do I know which orthodontic treatment is right for me?

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