Skip to content

Book A Free Exam

Virtual Consultation

Text Us (972) 390-1100

Call Us (972) 390-1100

Allen, TX
(972) 390-1100

Español

Doctor Referral Form

New Patient Form

Home
About Us
New Patients
Braces 101
Treatments
Clear Aligners
- Invisalign
- 3M Clear Aligners
Contact Us

Home
About Us
New Patients
Braces 101
Treatments
Clear Aligners
- Invisalign
- 3M Clear Aligners
Contact Us

New Patient Form

Why Choose Us

Easy Financing

Types of Braces

Home Care

Patient Information Form

Patient Name(Required)

First Last

Nickname:

Email(Required)

Patient Address(Required)

Street Address City State ZIP Code

Birth Date:(Required)

MM slash DD slash YYYY

Cell Phone:(Required)

Gender

Male

Female

School / Employer's Name:

Grade / Position:

Interest/Sports:

Primary Responsible Party

Is the Primary Responsible Party the same as the above?(Required)

Yes

No

Primary Responsible Party Name:(Required)

DOB:(Required)

MM slash DD slash YYYY

Relationship to Patient:

Mother

Father

Step Parent

Self

Other

If Other , please specify:

Address

Street Address City State ZIP Code

Employer/Address:(Required)

Primary Party Cell:(Required)

Primary Social Security Number:(Required)

Primary Email Address:(Required)

Secondary Responsible Party

Is there an additional Responsible Party?(Required)

Yes

No

Secondary Responsible Party Name:(Required)

DOB:(Required)

MM slash DD slash YYYY

Relationship to Patient:

Mother

Father

Step Parent

Self

Other

If Other , please specify:

Address

Street Address City State ZIP Code

Employer/Address:

Secondary Party Cell:(Required)

Social Security Number:(Required)

Secondary Party Email Address:(Required)

How Did You Hear About Us?(Required)

Dentist

Patient

Relative

Acquaintance

Other

If Other , please specify:

Present Dentist:

Reason For Consultation:(Required)

Check if the patient has a history of the following:

ADD/ADHD

HIV/AIDS

Allergies

Anemia

Arthritis, Rheumatism

Autism

Asthma

Autoimmune

Bone Disorders

Bulimia

Cancer

Cerebral palsy

Chest pains

Chronic neck pain

Clicking of jaw

Cold Sores/Herpes

Diabetes

Diet pill usage

Downs Syndrome

Drug allergies

Endocrine problems

Emotional disorders

Epilepsy

Fainting, Dizziness

Glaucoma

Headaches

Heart Condition

Hepatitis

High Blood Pressure

Immune problems

Kidney Problems

Latex Allergy

Low Blood Pressure

Mouth breathing

Muscular disorders

Nervous Disorders

Organ Transplant

Painful chewing

Periodontal problems

Pneumonia

Pregnant

Prolonged Bleeding

Rheumatic Fever

Scoliosis

Seizures

Sicca

Smoking/Tobacco

Speech problems

TMJ problems

Tooth Grinding

Tuberculosis

Venereal Disease (STD)

Sinusitis

Prosthetic Joints

Bone Medications

Any disease, problems, or allergies not mentioned above?

Current Medications?

Females: Have you started Menstruating?

At what age?

Have wisdom teeth been extracted?

Any face, mouth or teeth injuries?

Does the patient normally breathe through the mouth while awake or asleep?

Do gums bleed when brushed or flossed?

When was your last dental cleaning and check up?

Any pending dental work?:

Have you had previous orthodontic treatment?

Are there any missing or extra teeth?

Have the Tonsils and adenoids been removed?

Any oral habits such as thumb-sucking or nail-biting?

Names and Ages of Brothers & Sisters:

Insurance Information

(Please fill out completely so we may properly file your insurance)

Primary Orthodontic Insurance:

Insurance Telephone:

Member ID Number:

Group Number:

Policy Holder's Name:

Relationship:

Mother

Father

Step Parent

Self

Other

If Other , please specify:

Policy Holder's Date of Birth:

MM slash DD slash YYYY

Secondary Orthodontic Insurance:

Insurance Telephone:

Member ID Number:

Group Number:

Policy Holder's Name:

Relationship

Mother

Father

Step Parent

Self

Other

If Other , please specify:

Policy Holder's Date of Birth:

MM slash DD slash YYYY

Signature

Relationship To Patient:

This field is hidden when viewing the form

Date:

MM slash DD slash YYYY

604 S Watters Rd Suite 150
Allen, TX 75013
Call Us: (972) 390-1100
Text Us: (972) 390-1100
Hours:
M-Th: 8am-5pm
F: 8am-1pm

Facebook-f Google Instagram Youtube

Find Us

Get In Touch

Invisalign Provider Allen Orthodontist in Allen, TX

iTero Digital Practice Allen Orthodontist in Allen, TX

Back To Top

About Us
New Patients
Braces 101
Treatments
Clear Aligners
Contact Us

About Us
New Patients
Braces 101
Treatments
Clear Aligners
Contact Us

Sitemap
Privacy Policy
Anti Spam Policy
Statement of Accessibility

Sitemap
Privacy Policy
Anti Spam Policy
Statement of Accessibility

© Copyright 2025 Orthodontist Allen TX Invisalign Braces | Allen Orthodontist ⁃ Site Design by: Kaleidoscope®

Best Orthodontist in Allen TX

Are you looking for an Invisalign orthodontist near me in Allen, TX? Dr. Maryam Mojdehi-Barnes offers expert orthodontic treatment—early orthodontic treatment for children, orthodontics for teens, and adult orthodontics with affordable braces and Invisalign clear aligners. We are the right choice for your orthodontic treatment, offering unmatched value on the cost of braces near me, the cost of Invisalign clear aligners, braces for kids, adult braces, and flexible payment plans for your new smile.

Home
About Us
New Patients
Braces 101
Treatments
Clear Aligners
- Invisalign
- 3M Clear Aligners
Contact Us

Schedule Free Exam

New Patient Form
Doctor Referral Form

Español