First Name:<\/label>*<\/span><\/div>

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Last Name:<\/label>*<\/span><\/div>

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Male\/Female<\/label>*<\/span><\/div>

<\/span>Male<\/label><\/div>

<\/span>Female<\/label><\/div><\/div><\/div><\/div><\/div><\/div>

Birthdate<\/label>*<\/span><\/div>

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Medical History:<\/label>*<\/span><\/div>

List any medical problems as well as any allergies and medications being taken:<\/textarea><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"9\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_textarea\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_textarea\" ><div class=\"wdform-label-section wd-width-100 \">    <label  for=\"wdform_9_element6\" class=\"wdform-label\">Dental History:<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-width-100\" ><textarea class=\"wd-width-100\"                      id=\"wdform_9_element6\"                      name=\"wdform_9_element6\"                      placeholder=\"\"                      data-value=\"Please include any trauma to face or teeth, any missing or extra teeth, any TMJ problems as well as what are your main concerns that you would like orthodontic treatment to accomplish: \"                      maxlength=\"\"                      style=\"height: 100px;\"                      >Please include any trauma to face or teeth, any missing or extra teeth, any TMJ problems as well as what are your main concerns that you would like orthodontic treatment to accomplish: <\/textarea><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"5\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_text\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row wd-align-items-center\">    <label  for=\"wdform_5_element6\" class=\"wdform-label\">Responsible Party Contact: Cell Phone or Email:<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-100\" ><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_5_element6\"                           name=\"wdform_5_element6\"                           value=\"\"                           data-value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"10\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_submit_reset\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_submit_reset\" ><div class=\"wdform-element-section wd-flex  wd-flex-row wd-justify-content-left wd-width-100\" ><button  type=\"button\" class=\"button-submit\" onclick=\"fm_submit_form('6');\"  data-ajax=\"0\"><span class=\"fm-submit-loading spinner fm-ico-spinner\"><\/span>Submit<\/button><button  type=\"button\" class=\"button-reset \" onclick=\"fm_reset_form(6);\" >Reset<\/button><\/div><\/div><\/div><\/div><\/div><div valign=\"top\" class=\"wdform_footer wd-width-100\"><div class=\"wd-width-100\"><div class=\"wd-width-100 wd-table\" style=\"padding-top:10px;\"><div class=\"wd-table-group\"><div id=\"6page_nav1\" class=\"wd-table-row\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_preload\"><\/div><input type=\"hidden\" name=\"fm-current-page\" value=\"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/75\" \/><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>If you are a new patient, please  fill out and submit the health history form below. We will contact you shortly. Complimentary ConsultationWe would like to offer you a complimentary consultation at our office conveniently located in Carmel Valley so we can create a treatment plan to suit your needs. To experience state-of-the-art orthodontic care, […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":22,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-onecolumniframe.php","meta":{"ngg_post_thumbnail":0,"footnotes":""},"aioseo_notices":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/75"}],"collection":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/comments?post=75"}],"version-history":[{"count":25,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/75\/revisions"}],"predecessor-version":[{"id":1795,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/75\/revisions\/1795"}],"up":[{"embeddable":true,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/22"}],"wp:attachment":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/media?parent=75"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}