Lakeshore Orthodontics is dedicated to providing your family with the very best orthodontic care in a supportive and caring manner. We believe our office should be a friendly, welcoming environment that patients enjoy visiting. Due to the Covid-19 outbreak and the severity of the situation, we feel it is necessary to make changes to ensure the safety of our patients and team. The office may appear different, but our mission remains the same.

New Patient Registration

Medical Dental History Adult Form


Closest Relative


Other dentists/dental specialists now being seen:


Other physicians/health care providers being seen now:

General Information

Financial Responsibility

Dental Insurance

Medical Insurance

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don’t know/understand (dk/u).

Medical History

Now or in the past, have you had:

Have you had allergies or reactions to any of the following?

Dental History

Now or in the past, have you had:

Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.

Family Medical History

Release and Waiver