New Patient Form

"*" indicates required fields

Please fill out your registration and health history information online! This form has been designed for both children and adults. After completing this confidential questionnaire, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. We will have your information when you arrive for your evaluation appointment. If you wish us to complete a complimentary insurance benefits check, please complete the insurance portion of the form.

Responsible Party Information (For minors)

Mailing Address (if different)

Mailing Address (if different)

Emergency Information


General Information

Dental Insurance Information

We offer a complimentary dental insurance benefits check. If you check YES to the first question below, please fill out the rest of this section COMPLETELY with your dental insurance information for us to verify your benefits ahead of time. If NO, please fill out "n/a" on the fields below.
Do you have dental insurance you wish us to check?*
Insurance Company Claims Address*

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues as they may affect the treatment you receive from our office. This information is kept strictly confidential.
MEDICAL HISTORY: Check all that apply.
Is the patient allergic to any medication?
Is the patient taking any medications? Please list and describe:
Does the patient have a history of any major illness?
Has the patient had any major operations?
Has the patient ever been involved in a serious accident?
Is the patient pregnant?
Does the patient use tobacco?
Now or in the past, has the patient ever had
Has the patient ever had allergies or reactions to any of the following?
DENTAL HISTORY: Now or in the past, has the patient ever had


MM slash DD slash YYYY

Patient Photo Release

hereby authorize Graber & Gyllenhaal Orthodontics or any of their assignees to take photographs/video images of my teeth, jaws, and face. I understand that the photographs/video images will be used as a record of my care and may be used for communication with other healthcare professionals, educational publications (orthodontic journals), and education lectures. The content may also be used for marketing or advertising purposes (including website publication, social media posts, etc.). I further understand that if the photographs, videos, and/or testimony are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs, slides or videos. If I wish to revoke this consent, I may do so in writing.
Please check one option*

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out: -Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); -Obtaining payment from third-party payers (e.g. my insurance company); -The day-to-day healthcare operations of your practice I have been informed of, and given the right to review and secure a copy of your Notices of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you to obtain the most current copy of this notice. I understand that I have the right to request restriction on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.