Become a Patient — Covington, WA

New Patient Form

New Patient Form

Patient Details

Additional Patient Details

Guardian #1 / Insurance Information

Insurance Information (If Applicable)

Guardian #2 / Insurance Information

Orthodontic Insurance (If Applicable)

Sleep / Airway Issues

Dental / Medical History

Please check if the patient has a history of the following medical conditions:

Dental Questions


Please check if the patient has, or ever had, any of the following habits?

Signed Consent

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status. I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient. I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

By submitting this form you agree to the above mentioned consent statement