North Bend: 425-888-1896 | Snoqualmie: 425-831-0386 | Maple Valley: 425-413-2121 | Enumclaw: 360-625-9868

Our team at Kirby Nelson Orthodontics knows that you are busy, so we want to make sure your visit with Dr. Nelson, Dr. Katz, or Dr. Roberts is productive and time-efficient. Our patient forms can be completed and easily submitted electronically to our office from this page.

We encourage you to complete the new patient forms prior to your complimentary orthodontic consultation, allowing us to spend the entire time focusing on you and giving you sufficient time to ask any questions you may have.

You may also print the forms, fill them out by hand, and bring them into the office with you.

We look forward to meeting you soon!  If you have any questions or need help locating or completing the forms, please feel free to call us in North Bend, Snoqualmie, Maple Valley, or Enumclaw, Washington. We are here to help in any way that we can!

Patient Information
Medical/Dental History
Does patient have any illness or physical condition we should know about?: Yes No
Has patient been to a physician in the last 6 months?: Yes No
Has patient been to a dentist in the last 6 months?: Yes No
Have any teeth (including "baby teeth") ever been extracted by your dentist?: Yes No
Have any permanent teeth ever been injured or loosened by a fall?: Yes No
Are any of the following conditions present in patient's present or past history:
If patient is a minor, please answer the following questions:
Any noticeable difficulty in breathing through the nose?: Yes No
Does the patient have speech problems?: Yes No
Has patient had speech or tongue therapy?: Yes No
Has thumb sucking been a habit after the age of 6?: Yes No
Has tongue thrust been a habit after the age of 6?: Yes No
Has mouth breathing been a habit after the age of 6?: Yes No
Responsible Party Information(Same as Patient)
If patient is a minor please fill out the following:


Contractual financial arrangements for service fees will be subject to approval of credit and may require a credit report.


Dental Insurance Information
 
Do you have secondary dental insurance? Yes No
 
HIPAA

I acknowledge that I have received the Statement of Privacy Practices for the offices of Kirby Nelson Orthodontics.


Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.