Patient Forms

We are always excited to meet new patients during their first visit to our office. We will make every effort to ensure that your first visit with us is a comfortable and educational experience.

For your convenience prior to your first appointment, you may download our New Patient Forms. Print the form by clicking on the link below. Once completed, it can be faxed, mailed, or brought with you on the day of your consultation.  You can also fill out the form directly on our website:

Adult Medical History Form
TMD/TMJ Health History Form
Minor Child Health Form

A Holistic Approach to Orthodontics

Schedule An Appointment

Call us at (678)352-0919

American Council of holistic medicine logo
American Academy of Facial Esthetics logo
American association of orthodontists
Southern Association of orthodontists
International college of cranio mandibular orthopedics logo

Dr. J. Michael Dierkes, DDS, MS, NMD is a nationally recognized orthodontic specialist who has been creating beautiful smiles for over 30 years. His services have improved the lives of people from Roswell and the surrounding areas, including residents of Sandy Springs, Alpharetta, Marietta, and Atlanta. Whether you are an adult, a child, or a teenager, our knowledgeable staff is committed to helping you achieve the radiant, beautiful smile you deserve. Please call us today to schedule your initial consultation!