New Patients

Our New Patient Forms are available for download in printable format so that you can complete your forms at your convenience prior to your new patient consultation. Please carefully review our policies and procedures outside of the office. You can bring your completed new patient forms to your appointment or email them to


For patients under the age of 18, please use the “Child Medical History” form.

Southern Smiles is the premier choice for orthodontics in Roanoke Rapids, NC. Call (252) 365-4234 to take the first step to the smile you always wanted!

    *This form is not intended for submission of personal medical information.