Patient Forms

Smile Logic Orthodontics has a business associate agreement (BAA) with Google that secures protected health information (PHI) you send to us with these electronic forms.

New patient forms

Patient registration (PDF) and health history (PDF) forms can be printed and mailed to 346 Georges Rd, Dayton NJ 08810 or emailed to info@smilelogicortho.com.

Online registration and health history is available using the form below:


COVID-19 pre-visit questionnaire

  • Pre-visit questionnaire - use this for all in office visits during the COVID-19 Pandemic. As of May 26, 2020 our office is open for placement, adjustment, and removal of braces and aligners.

Insurance forms

Our virtual braces request form has the information we need to get started, but if necessary, here are some additional options.

  • Policy only - use this form if you have not started treatment and would like us to use your insurance policy information to check your orthodontic benefit.
  • Assignment of benefit only - use this form to authorize payment from an insurance carrier to Smile Logic Orthodontics.
  • Policy and assignment of benefit - use this form if your benefits change during treatment and you need to update your insurance policy information and authorize payment from an insurance carrier to Smile Logic Orthodontics.

Traditional paper forms