New Patients

Start your smile the right way.

The official Dillehay Orthodontics New Patient Registration — fill it out online and we'll generate a signed PDF, or download the blank form to bring with you.

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Why Choose Us

50+ years of family-owned care, board-certified doctors, and a team that treats you like family.

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Your First Visit

A relaxed exam, digital records, and a clear treatment plan — often with same-day starts.

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Free Consultation

No pressure, no cost. We'll walk through your smile goals and options together.

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Your First Visit

About an hour — and you'll leave knowing exactly what's next.

Warm welcome

Meet your care team and take a quick tour of the office.

Digital records

Low-radiation imaging and photos — no goopy impressions.

Doctor exam

One of the Dillehays reviews your smile and answers questions.

Custom plan

Timing, options, and transparent pricing — all in one visit.

Patient Forms

Fill it out online, or bring it printed.

Save time in the office. Complete the digital form and we'll generate a signed PDF, or download the blank two-page form (child or adult) to fill by hand.

Fill out digitally

New Patient Registration

Digital version of the official Dillehay Orthodontics intake form.

Patient type

Child (under 18)Adult

Patient Information

Last name *First name *NicknameSexHome addressPhone *Today's dateAgeBirthdate *SchoolHeightWeight

Responsible Party 1

NameRelationshipAddress (if different)PhoneBusiness / employerBusiness phoneInsurance companySS #Policy #BirthdateEmail

Responsible Party 2 (optional)

NameRelationshipAddress (if different)PhoneBusiness / employerBusiness phoneInsurance companySS #Policy #Birthdate

Referral & Interests

Other family members seen by our doctorsHow did you first hear of our office?General dentistChild's favorite hobbies & interests

Physician & Recent Care

When was the last physical exam?Physician namePhysician addressCity / stateZip

Child Medical History

Answer yes or no. Your answers are for our records only and will be considered confidential.

Is your child in good health?

Has there been any change in your child's general health within the past year?

Is your child now under the care of a physician?

Has your child ever had any serious illness or operation?

Has your child ever had joint replacement surgery?

Has your child ever been hospitalized or had a serious illness in the past 5 years?

Rheumatic fever / rheumatic heart disease?

Congenital heart lesions?

Cardiovascular disease?

Pain in the chest upon exertion?

Shortness of breath after mild exercise?

Shortness of breath when lying down / requires extra pillows?

Cardiac pacemaker?

Heart valves replaced?

Heart bypass surgery?

Allergies?

Sinus trouble?

Asthma / hay fever?

Hives / skin rash?

Fainting spells / seizures?

Diabetes?

Urinates more than 6 times a day?

Thirsty much of the time?

Frequent dry mouth?

Hepatitis, jaundice or liver disease?

Stomach ulcers?

Kidney trouble?

Tuberculosis?

Persistent cough / coughs up blood?

Low blood pressure?

Abnormal bleeding with previous extraction, surgery, or trauma?

Bruises easily?

Ever required a blood transfusion?

Any blood disorder such as anemia?

Surgery / x-ray treatment for a tumor or growth of head/neck?

Is your child taking any drugs / medication?

Any serious trouble with previous dental treatment?

Any other condition we should know about?

Regularly exposed to x-rays or ionizing radiation?

Wearing contact lenses?

If "yes" to under physician care — reasonSerious illness / operation detailsHospitalized in past 5 years — detailsBlood transfusion detailsCurrent medications (list)Serious trouble with prior dental treatmentAny other condition we should know aboutOther disease / condition

Currently Taking

Antibiotics / sulfa drugs

Anticoagulants (blood thinners)

Medicine for high blood pressure

Cortisone (steroids)

Tranquilizers

Antihistamines

Aspirin

Insulin / tolbutamide / similar

Digitalis / heart drugs

Nitroglycerin

Oral contraceptive / hormonal therapy

Other medications

Allergies / Adverse Reactions

Local anesthetics

Penicillin / other antibiotics

Sulfa drugs

Barbiturates, sedatives, sleeping pills

Aspirin

Iodine

Codeine / other narcotics

Other allergies

Females (if applicable)

Are you / is she pregnant?

Any problem associated with menstrual period?

Chief Dental Complaint

Privacy, HIPAA & Consents

Please review and acknowledge each item below. All acknowledgements are required before your PDF can be generated.

HIPAA Notice of Privacy PracticesI acknowledge that I have been offered a copy of Dillehay Orthodontics' Notice of Privacy Practices, which describes how my protected health information (PHI) may be used and disclosed for treatment, payment, and healthcare operations in accordance with HIPAA.Consent for Orthodontic Evaluation & TreatmentI authorize Dillehay Orthodontics and its clinical staff to perform an orthodontic evaluation, diagnostic records (including photographs and low-dose radiographs), and any treatment agreed upon in my care plan.Financial ResponsibilityI understand that I am financially responsible for all charges not covered by my insurance and that any insurance benefits quoted are an estimate, not a guarantee of payment.Communications ConsentI consent to be contacted by Dillehay Orthodontics via phone, email, or SMS regarding appointments and my care. Msg & data rates may apply. Reply STOP to opt out of SMS.Accuracy of InformationI certify that the information provided on this form is true and complete to the best of my knowledge, and I will notify the office of any changes.

Signature (type full name) *Date *

Complete patient name, all acknowledgements, and sign to enable download.