• Child Patient Information Form

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  • Parent 1

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  • Parent 2

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  • Dental Insurance

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  • NOTICE: DO NOT SIGN THIS AGREEMENT BEFORE YOU READ AND AGREE TO THE CONDITIONS ABOVE. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN.

  • Medical History

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important role with the dentistry you receive. Thank you for answering the following questions:
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  • HIPAA RELEASE AND WAIVER

    (Guide to Patient Privacy Rules Is in Waiting Room)
  • Signature For Health History

    I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
  • Clear
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  • Should be Empty: