• 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 (it has not been submitted until you see a ✓ COMPLETE message, be sure to fill in all required fields).
Adult New Patient Form
Child New Patient Form
• Click here to read our complete HIPAA policy.

Supplemental Informed Consent (ONE TIME)
COVID Health Questionnaire  (PER VISIT) This form must be submitted prior to every appointment as per the American Association of Orthodontists. Be sure to fill in every field, such as ‘N/A’ if something is not applicable.

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)