Initial Examination Information Request

To request an appointment, please fill out and submit the form below. We will contact you to make the necessary arrangements for your appointment.

Please note this request form is for non-urgent appointments only. If you have an orthodontic problem that you feel requires urgent attention, please contact us directly by phone 248-644-5400.

Name:First and Last

Address:Street/ City/ Zip

Day-Time Phone Number

Alternate Phone Number

Email Address:valid email address

I would like to:

Are you currently a patient with us?

Yes No

If you are a new patient, where did you first hear about the practice?

Additional Information:

Verification Code:(case sensitive)

Orthodontic Associates

Initial Examination Information Request