New Patient Form

Submit your health history form online to your orthodontist today. Blue Wave Orthodontics Logo
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 and click “submit”. Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

Patient Information

First
Last

Street Address
City
State
ZIP Code

Patient Information

First
Last

Street Address
City
State
ZIP Code

Street Address
City
State
ZIP Code







Dental Insurance Information



IF YES:



Emergency Information


What are the main concerns that you would like orthodontics to address?


Has the patient ever had any of the following medical problems?

Does/Has the patient have/had any of the following habits?

Signatures

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!