Patient Information
Braces By DiMassa and Wenger
Child New Patient Form
Please bring your Dental Insurance Card to your exam appointment,
or print one off of your insurance company's website.  
Mother's Primary Information
Father's Primary Information
How else have you heard of us? (Check the box for all that apply) *
Medical History
Has your child ever had any of the following medical issues?
Adenoids (removed) *
Allergies *
Blood Disorders *
Chicken Pox *
Diabetes *
Epilepsy *
Healing Ability (Poor) *
Heart Disorders *
HIV + /AIDS *
Hospitalized for Sickness or Injury *
Injuries *
Is Patient Under Treatment at this TIme *
Measles *
Medication Now Being Taken *
Mumps *
Rheumatic / Scarlet Fever *
Tonsils (removed) *
X-Ray Treatment (Not Diagnostic) *
Is patient covered by dental insurance?
Is patient covered by secondary dental insurance?
Has the patient had previous orthodontics consultation or treatment?
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 this office of any changes in patient's medical status. 
I Agree to the above terms and conditions *