Skip to main content

Patient Intake Form














    Are you allergic to, or ever had a reaction to:




    Photo Release Form

    Straight Smiles would like your permission to use images taken of your child to showcase our practice on our website and social media.

    DECLARATION

    Dr. Scramstad is a GP Dentist Providing Orthodontics only.

    Patient Signature

    Parent Signature (If Patient is a Minor)