Book a free consultation
Book a free consultation

New Patient Intake Form

By completing the intake form prior to your appointment, we can better understand your unique needs and tailor our treatment approach accordingly. Your comfort and well-being are our top priorities, and this intake form helps us deliver personalized and comprehensive care. 

Thank you for choosing Mona Afrand Orthodontics, and we look forward to meeting you soon!

Tell Us About Yourself

To ensure we provide you with the best possible care, we kindly ask all new patients to fill out our New Patient Intake Form. This form collects important information about your medical history, dental background, and any specific concerns or preferences you may have.

New Patient Intake Form

"*" indicates required fields

YYYY dash MM dash DD
YYYY dash MM dash DD

Health question for patient

Is your general health good?*
Physical or medical difficulties?*
Any allergic reasons? (such as latex)*
Taking any medications?*
Have tonsils been removed?*
Have family members has orthodontic treatment?*
History of thumb sucking?*
Is patient a mouth breather?*
Is there a speech problem?*
Any wind or brass instruments played?*

Information for child Patient

YYYY dash MM dash DD
This field is for validation purposes and should be left unchanged.
crossmenu linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram