New patient form

Please complete the below forms before your consultation so we can have this information ready before you begin treatment.

Fields marked * are required.

Patient details

Responsible Party Information (The Person who is responsible for paying for your treatment)

First Responsible Party

Second Responsible Party


Other than the responsible parties listed above, are there any other individuals or legal guardianship arrangements, in place that require specific consent for the patient to elect treatment and/or who need to be involved in the ongoing management of the orthodontic treatment?*


Emergency Information

General Information