Medical History and Consent Forms 
Welcome to Gentle Braces please fill out the following questions to better serve you!
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Email *
How did you hear about us? *
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First Name and Last Name: *
Title:
 *
Date of Birth  *
MM
/
DD
/
YYYY
Martial Status *
Phone Number *
Address *
Street Address, City, State, & Zip Code
Emergency Contact Information *
  • First and last name 
  • Relationship toward the patient 
  • Email:
  • Street Address, City, State and Zip Code:
  • Phone Number
  • Occupation 
  • Employer 
Dentist Information *
  • General Dentist Name:
  • Last seen:
  • Reason for appt:
  • Next appt:
  • Phone number of Dentist:
If you have not seen a General Dentist you can simply type, "Have not seen dentist yet".
What concerns do you have about your teeth? *
Have you had previous orthodontic treatment?
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Do you have Dental Insurance?  *
If you do have dental Insurance please text us a picture of your insurance card!
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Required
If you have Dental Insurance Please Fill below: 
Keep in mind this is simply a verification of benefits, if you do not have dental insurnace you can simply skip this section, Thank you!
Full Name of the Insured (Subscriber) :
Date of Birth
MM
/
DD
/
YYYY
SSN OR MEMBER ID #:
Insurance Company Name 
On the back of your insurance card, what is the Dental Provider phone number?:
Group Number:
Relationship with insured?:
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Employment Status:
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