Welcome!

We’re so excited to have you as the newest member of the Beecroft Family! 🤗

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Please take a minute to either print and complete OR fill out the below patient information form before your first appointment at Beecroft Orthodontics.

 

Complete the New Patient Form Online here:

Patient Information
Patient Name *
Patient Name
Birthday *
Birthday
Address *
Address
Phone
Phone
Emergency Contact Phone: *
Emergency Contact Phone:
Parent/Guardian 1
Required if Patient is under 18 years old.
Name of Parent/Guardian 1
Name of Parent/Guardian 1
Birthday of Parent/Guardian 1
Birthday of Parent/Guardian 1
Address of Parent/Guardian 1
Address of Parent/Guardian 1
Phone of Parent/Guardian 1
Phone of Parent/Guardian 1
Parent/Guardian 2
If Patient is under 18 years old.
Name of Parent/Guardian 2
Name of Parent/Guardian 2
Date of Parent/Guardian 2
Date of Parent/Guardian 2
Address of Parent/Guardian 2
Address of Parent/Guardian 2
Phone of Parent/Guardian 2
Phone of Parent/Guardian 2
Insurance Information
Please let the Front Desk know if you have secondary insurance.
Policy Holder Name
Policy Holder Name
Birthdate of Policy Holder
Birthdate of Policy Holder
Phone of Policy Holder
Phone of Policy Holder
Work Phone of Policy Holder
Work Phone of Policy Holder
Medical History
Date of Last Visit
Date of Last Visit
Medical Conditions
Check any of the medical conditions that you have or currently have:
Dental History
Date of Last Visit:
Date of Last Visit:
Are you presently in any dental pain?
Have your wisdom teeth been removed?
Have there been any injuries to face, mouth, or teeth?
Do you have any type of thumb or tongue habit?
Do your teeth or jaws ever feel uncomfortable when you awake ?
Are you aware of your jaw clicking or popping?
Have you ever been told that you grind your teeth?
Confirmation
Submit *