Skip to Main Content

About
Services
Children
Teens
Adults
Patients
Contact

Your Meridian & Laurel Provider

Search

Facebook

Your Meridian & Laurel Provider

Meridian
Laurel
Referrals

About
Services
Children
Teens
Adults
Patients
Contact

Request Consultation

Search

New Patient Form

Welcome! You've booked your first appointment at Douglas Orthodontics, so let's get started. Please take a few minutes to complete our New Patient Form below.

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone (Primary) *

Phone (Secondary)

Address *

City *

Zip Code *

Family Physician *

Family Dentist *

Does the patient have any relatives who have had treatment in this practice? *

Yes

No

Unsure

Does the patient have dental insurance that covers orthodontic treatment? *

Yes

No

Unsure

Parent / Guardian Information

If completing this form for a minor, please complete parent / guardian information below.

First Name *

Last Name *

Relationship to Patient *

Phone (If different from above)

Address (If different from above)

Medical History

Have you previously consulted another orthodontist? *

Yes

No

Have you had any previous orthodontic treatment? *

Yes

No

Are you currently taking any medication? *

Yes

No

If yes, please list *

Are you in a high risk group for HIV Infection? *

Yes

No

Allergies *

Yes

No

Do you have a history of any serious illness? *

Yes

No

Have you had injuries to the head? *

Yes

No

Have you been informed of any missing or extra teeth? *

Yes

No

Does the patient have a history of any of the following? (Check all that apply) *

Anemia

Bone Disorders

Diabetes

Epilepsy

Fainting or Dizziness

Heart Trouble

Gland or Endocrine Problems

Rheumatic Fever

Nervous Disorders

Congenital Abnormalities

Emotional Disorders

Tuberculosis

Liver Problems

Blood Disorders

Hepatitis

HIV Infection

Prolonged Bleeding

Kidney Problems

Frequent Colds

Asthma

Ear Infections

Chronic Nasal Obstruction

Mouthbreathing

Adenoid Problems

Tonsillitis

Tongue thrusting

Tooth grinding or clenching

Headaches (frequent)

Muscular soreness around head and neck

Jaw joint clicking of popping

Thumbsucking

Finger sucking

Lip biting or sucking

N/A

Have you received treatment for any of the above problems? *

Yes

No

Have your tonsils been removed? *

Yes

No

Unsure

Have your adenoids been removed? *

Yes

No

Unsure

Dental History

Do you have regular dental checkups? *

Yes

No

Date of Last Checkup *

Tooth Brushing *

After every meal

Once per day

Twice per day

Do you floss? *

Yes

No

Reason for seeking orthodontic consultation? *

I hereby acknowledge that the health history provided is correct. *

Yes my information is correct

Spam Blocker

No Referral Needed

Whether you’re considering treatment for yourself or your child, we'd love to hear from you. Get started on your orthodontic journey at Douglas Orthodontics today!

Contact Meridian Contact Laurel

Meridian Office
2400 16th St Meridian MS 39301 US

(601) 483-4522

Contact our Meridian Office
Monday: 8:00 am - 4:30 pm

Tuesday: 8:00 am - 4:30 pm

Wednesday: 8:00 am - 4:30 pm

Thursday: 8:00 am - 4:30 pm

Friday: Closed

Saturday: Closed

Sunday: Closed
Laurel Office
1945 Pine Belt Dr Laurel MS 39440 US

(601) 778-0367

Contact our Laurel Office
Monday: 8:00 am - 4:30 pm

Tuesday: 8:00 am - 4:30 pm

Wednesday: 8:00 am - 4:30 pm

Thursday: 8:00 am - 4:30 pm

Friday: Closed

Saturday: Closed

Sunday: Closed

Home
About
Services
Children
Teens
Adults
Patients
Contact

Accessibility Statement
Privacy Policy
Search
Sitemap

Facebook

Copyright © 2025. All Rights Reserved. Managed with Tymbrel