Best way to reach you during business hours:
Other family members have had:
Person financially responsible:
SelfOther (If other, please list name, address, and phone number below)
Do you have orthodontic insurance coverage?
NoYes (please specify)SelfOther
Please check any of the following for which the patient has been treated:
ADD or ADHDAnemiaArthritisArtificial JointAsthmaAutismTuberculosisEndocrine (Hormonal)Epilepsy / SeizuresFainting & dizzinessGrowth DisorderHeart MurmurHeart ProblemsHIV / AIDSLatex AllergyLiver ProblemsMononucleosisNervous DisordersRheumatic FeverThyroidKidney ProblemsBleeding DisordersBone DisordersDiabetesHepatitisOther
Please answer the following questions:
I, the undersigned, certify that I have read and understand the above medical and dental information, have
reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognize that it is my
responsibility to infrom this office. I also give my permission for clinical examination.