If you want to make new patient exam appointment for you or you sibling, and you reached us outside business hours,? please use below open appointment availability. We appreciate keeping these appointment and give us 48 hours phone call if not able to keep selected appointment.

    Child's/Patient's Information

    Father's Information

    Mother's Information

    Person Responsible for Account

    FatherMotherOther

    YESNO

    Crooked TeethCrowdingClose SpacesCross BiteBad BiteHard to ChewCan't close mouthJaw PainHeadachesDon't like smileCosmetics

    Dental Information

    YesNo

    YesNo

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    About Patient Home Care

    FairGoodPoor

    NoYes

    NoYes

    Mouth breathingGrinding of teethThumb suckingLeaning on chin or faceNail/lip biting

    Medical Information

    PoorFairGood

    NoYes

    NoYes

    AsthmaBlood DiseaseDiabetesHepatitisAIDS/HIVBlood DiseaseRheumatic FeverAnemiaHeart DiseaseAllergiesGlaucomaEpilepsyBone DisorderNone

    Ear InfectionsColdsSore Throats

    Agree To Terms

    I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of Dr. Masri. I understand that where appropriate, credit bureau reports may be obtained.

    Yes, I agree to the above terms & conditions.