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Patient Forms

Please complete the form below prior to your first visit. If you have any issues or complications, do not hesitate to contact our office.

Patient Information

Responsible Party Information

Same as Patient Address
Same as Patient Address

Dental Insurance Information

A dental insurance policy is a contract between the insured and the insurance company. Therefore, the patient or person responsible for the account is responsible for paying all fees to our office. We will gladly assist you in submitting insurance claims pertaining to any charge for care in our office.

A parent/guardian must answer the following questions and sign for children under 18 years of age. Your answers will be kept confidential and will be an aid in selecting the safest and most effective means of providing your orthodontic care. If you do not understand a question or wish to discuss it with Dr. Cordes, please mark an “X” next to the question.

Medical and Dental History

Please check if you have had any of the following conditions

Wear or fractures of teeth
Difficulty with cleaning related to tooth alignment
Bone or gum tissue loss
Alignment of teeth prior to dental work (crowns, bridges, etc.)
Jaw or muscle tightness

Muscular soreness around head and neck
Clenching/Grinding teeth
Mouth breathing
Headaches (more than normal)
Jaw joint popping/clicking
Speech problems
Periodontal "Gum Problems"
Ringing in ears
"Dead Teeth", root canals treated
Bleeding gums, bad taste, mouth odor

To the best of my knowledge, the answers I have given are accurate. I also understand that it is very important to report any changes in my medical or dental status to Dr. Cordes at the earliest possible time, and I agree to do so. I give permission to Dr. Cordes to obtain from my physician any additional information regarding my medical history that might be needed to provide me with the best treatment possible.


If printing form, please remember to bring completed form with you to your first visit.