The following information is essential for our office to provide orthodontic care in a manner that is compatible with the patient’s general health. Your cooperation in providing accurate information is necessary to meet your orthodontic needs safely and efficiently. Incorrect or incomplete information can be dangerous to your health. If you answer YES to any question please provide an explanation.
Does the patient have OR has the patient EVER had (a):
Please check all that apply.
Equal care will be provided to all patients, regardless of age, race, ethnicity, physical ability or attributes, religion, sexual orientation, gender identity or gender expression.