Tell Us About Your Child:

Please fill out the form and submit. Do NOT print and bring the form into the office.
Our office uses an Automated System for confirming all appointments. This system gives the option for calling and texts.
Best telephone number to use?

Medical History


Please Check the following As They Apply:

Please explain any other health problems and list all medications currently taking (including non-prescription drugs)
By signing below, I acknowledge receipt of a copy of the Notice of Privacy Practices of Innovative Orthodontics, Donihue Waters, DDS, MDS.

Parent's Information:

Responsible Party


Responsible Party


Insurance Information:


Upload Insurance Card


Upload Insurance Card
Our office files insurance as a courtesy for our patients. We cannot file your insurance without a copy of your insurance card. If you do not have a copy of your card, please contact your Human Resources Department.