New Patient Forms

In an effort to better our commitment to customer service to our patients, we have provided our new patient information forms on our website.   You have two options to complete this form prior to your new patient exam:

1. Fill the form out on your computer and email it to drb@macomborthodontics.com by clicking on the "Submit to Dr. Bieszki by Email" link located on the bottom of the completed form. NOTE, please save the data file that is generated from sending the form by email, in case the email you send doesn't get through to Dr. Bieszki—that way you can just send the data file again as an attachment instead of having to fill out the form a second time.  In addition, please also print out a filled in form to bring with you to the office as a backup in case of computer error.
   
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2. Print out a blank copy and fill out the form by hand prior to your new patient exam; please bring it with you when you come for your new patient consultation.

These forms are in Adobe Acrobat format- to view them, print them out, or fill them in on your home computer, you will need the free software linked below called Adobe Reader.  Just click on the link below to download the free software prior to opening the forms, if you don’t already have it loaded on your home computer. Go to Adobe's Web site to download Acrobat Reader >>

Below are the links for the forms.  One form is for children under 18, and the other is for adults over18.  You only need to fill out one age appropriate form per patient.  Once you have Adobe Reader, just click one of the icons below for the age appropriate form to view.

Over 18-Adult Patient Information Form.pdf
Under 18-Child Patient Information Form.pdf

Don’t worry if you can’t fill in all of the answers on your own, as we will review your answers at your appointment and finish any questions that you couldn’t answer completely.  We hope that you will find it relaxing to fill in the forms when it is convenient for you, in your own home.

If you would rather not email the forms to us, or can’t print them out at home and fill them out, don’t worry; we will complete them in the office at your initial visit.   We look forward to meeting you at your initial orthodontic consultation with Dr. Bieszki!