Call Us Today!
Kirkpatrick & Lai
New Patient Forms
FAQ
Emergency & Remedies
HIPAA
A family business for over 50 Years
Tulsa
(918) 747-1346
Tahlequah
(918) 458-5050
Miami
(918) 542-1867
Okmulgee
(918) 756-5070
Our Story
Invisalign
Testimonials
Media
Giving Back
Contact
Locations
Our Story
Media
Invisalign
Testimonials
Giving Back
New Patient Forms
FAQ
Emergency
Contact Us
Locations
Tulsa
(918) 747-1346
Tahlequah
(918) 458-5050
Miami
(918) 542-1867
Okmulgee
(918) 756-5070
Let’s Talk
Schedule an Appointment!
Patient Name
*
Phone Number
*
Email
*
Comments / Questions
Patient History
Name
*
First
Middle
Last
Prefers to be called
Birthdate
*
MM slash DD slash YYYY
Age
*
Hidden
Sex
Sex
*
Male
Female
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Engaged
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
School/Employer
*
Grade/Position
*
Email
(If over 18)
Home Phone
Work Phone
Cell Phone
*
Sibling(s) name(s) and age(s)
How did you hear about our office?
*
Dentist
Family Member
Other
Please Specify
Parent / Guardian (if patient under age 18)
Custodial Parent(s) Name(s)
Patient Lives With
(check all that apply)
Mother
Father
Stepmother
Stepfather
Grandparents
Other
Hidden
Do you have contact information for the patient's father/husband?
Yes
No
Not Applicable
Father's Full Name
*
First
Last
Title
Mr.
Dr.
Marital Status
Home Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
School/Employer
Grade/Position
Email Address
Home Phone
Cell Phone
Work Phone
Hidden
Do you have contact information for the patient's mother/wife?
Yes
No
Not Applicable
Mother's Full Name
*
First
Last
Title
Mrs.
Ms.
Miss
Marital Status
Home Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
School/Employer
Grade/Position
Email Address
Home Phone
Cell Phone
Work Phone
Hidden
Siblings: Name & Age
Hidden
Siblings: Name & Age
Hidden
Siblings: Name & Age
Hidden
How did you hear about our office?
Hidden
Responsible Party Email
Hidden
Patient Email (If Over 18)
Account Holder / Billing Information
Responsible Party Full Name
*
First
Last
Relation to Patient
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Best Contact Phone #
*
Hidden
Cell Phone
Do you have dental insurance?
*
(if yes, please ask for additional insurance form)
Yes
No
Is the patient on SoonerCare?
*
(only applies if under the age of 18)
Yes
No
Signature of Responsible Party
*
I certify the above information is true and correct to the best of my knowledge.
First
Last
Signature
Our Story
Media
Invisalign
Testimonials
Giving Back
New Patient Forms
FAQ
Emergency
Contact Us
▼
Locations
