Member - American Association of Orthodontists

Board Certified Othodontist - Adult and Childern

1068 East Ave # C
Chico, California 95926
Tel: (530) 345-0600

New Patient Registration

Whom can we thank for referring you to our office?

Patient Name:	*
DOB (mm/dd/yyyy)
Patient Address:
Patient City:
Patient State:
Patient Zip:
Patient Home Phone:	*
Patients Dentist:

Patient or parent: If this registration is for a dependant, please enter responsible parent information in the blue section. If for an adult patient, please use your own information.

Work phone (for parent if patient is a dependant):	ext:
Is it OK to use this number to reach you?	Yes No

Cell phone (for parent if patient is a dependant):
Is it OK to use this number to reach you?	Yes No

Patient/parent primary email:
Parent name (enter only if patient is a dependant):	Title Name (Title, First, Middle initial, Last)

Have we seen other family members?	Yes No
If yes, name(s):

Is this appointment for a second opinion?	Yes No
I have already called and set up the examination appointment:	Yes No
Please call me at this number to set an examination appointment:

Please write notes about anything that will be helpful.

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