Patient Information
Adult New Patient Form
Welcome to Braces Omaha. Our goal is to provide you with the highest quality orthodontic care available in Omaha in a fun and friendly environment. Trust your smile to the unparalleled expertise of Braces Omaha.

Information must be filled out completely

Employer Information
Spouse Information
Person Responsible for Account
Primary Orthodontic Insurance
Orthodontic Coverage *
Secondary Orthodontic Insurance
Orthodontic Coverage
Medical History
Do you have a personal physician *
Please describe your physical health *
For Women
Are you currently on a birth control pill? *
Are you pregnant? *
Are you nursing? *
What are the main concerns you would like orthodontics to address?
Have adeniods or tonsils been removed?
Have you been informed of any missing or extra permanent teeth?
Have you ever had any pain or tenderness in the jaw joint (TMJ, TMD)?
Do you brush your teeth daily?
Do you floss your teeth daily?
Have you ever had any of the following medical issues?
Abnormal Bleeding *
Allergies to any drugs *
Allergy to latex/metals *
Allergy to plastic *
Any Hospital Stays *
Any Operations *
Asthma *
Cancer *
Congenital Heart Defect *
Convulsions/Epilepsy *
Diabetes *
Handicaps/Disabilities *
Hearing Impairment *
Heart Murmur *
Hemophilia *
Hepatitis *
Kidney / Liver Problems *
Rheumatic / Scarlet Fever *
Tuberculosis (TB) *
Please list an emergency contact not living with you
Agree To Terms
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform Braces Omaha of any changes in patient's medical status. I also authorize Braces Omaha to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles, social media or promotional materials and are the property of Braces Omaha. I understand that where appropriate, credit bureau reports may be obtained.
I Agree to the above terms and conditions *