Intake Form: Adult

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Tacoma Office

2302 South Union Ave.
Suite B-14
Tacoma, WA 98405
(253) 752-3949

Monday-Friday
7:30am-4:30pm

Gig Harbor Office

5122 Olympic Dr. N.W.
Suite B-206
Gig Harbor, WA 98335
(253) 851-6789

Monday-Friday
7:30am-4:30pm

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Dental History
Medical History

Do You Have Any History Of The Following

Pre-medication needed?

Under physicians care at this time

CHECK ANY OF THE FOLLOWING FOR WHICH YOU HAVE BEEN TREATED

Are there any concerns regarding orthodontic treatment?