• Allen M. Zuch, DMD, MS
  • Adult & Child Orthodontics
  • 334 Underhill Ave, Ste 2C
  • Yorktown HEIGHTS, NY 10598
  • 914.245.6506

Health History Forms

We are pleased to offer the convenience of secure online forms. Please choose the appropriate form below. Upon completion, the form will submit directly to the office of Doctor Allen Zuch. Your information will be used for the sole purpose of your orthodontic treatment.

Step 1: Select the proper form, complete it, review it, click submit (Note: it has not been submitted until you see a ✓ COMPLETE message)
New Patient Form (Adult)
New Patient Form (Child)

Supplemental Informed Consent (For print)
Supplemental Informed Consent Online (For online completion)
Health Questionnaire PER VISIT (For print)
Health Questionnaire Online  PER VISIT (For online completion) This form must be completed prior to every appointment as per the American Association of Orthodontists. You can do it conveniently on your smartphone.
• Click here to read our complete HIPAA policy.

Step 2:
Please Register To The Patient Portal (your temporary password is emailed to you 24 hours after scheduling your appointment. Look for the subject: THE TOOTH MOVER Patient Online Portal)

Step 3:
We Look Forward To Your Visit At The Tooth Mover!