New Patient Form

Thank you for making an appointment with our office! Our goal is to help you reach and maintain  maximum oral health. Please fill out the form below completely and submit before your appointment. If you would like to print out the form to fill out by hand and bring to your appointment, please click here. The better we communicate, the better we can care for you.
New Patient Form
* required field

Welcome to Our Office













Responsible Party Information





















Are there other family members that are being seen by Dr. Oliver? *


Dental Insurance Information






Do you have secondary coverage?


Emergency Information








Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.


Dental History



Are you currently in pain? *
Your current dental health is *

Please check any of the following conditions that apply to the patient 







Health History




Have you ever had surgery or been hospitalized?

Your current physical health is 

Does patient have a history of any of the following?
























HIV+/Aids
Describe Heart Problems
Does patient require pre-medication? *

Authorization

I understand the above questions and have provided accurate answers to the best of my knowledge. It is my responsibility to inform this office of any changes in the patient's medical status. I understand that providing incorrect information can be dangerous to the health of those individuals treating the patient. I understand that once a diagnosis and treatment plan has been developed, the fees and methods of payment will be discussed with me and a financial agreement will be established. I understand that, when appropriate, credit reports may be obtained. I also authorize the release of any information regarding diagnosis and the records of any treatment or examination rendered to the patient during orthodontic care to thrid party payers and/or health practitioners. I also authorize use of any and all photographic pictures taken by Oliver Orthodontics to be used in clinical presentations, new patient consultations, and for advertising/marketing purposes. I understand that my dental insurance may pay less than the actual amount owed for services. I agree to be responsible for payments of all services rendered on my or patient's behalf. Do you agree to the above statement? *






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