• PATIENT INFORMATION


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  • DENTAL INSURANCE

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  • EMERGENCY CONTACT

  • GENERAL INFORMATION

  • DENTIST

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  • For the following questions, please mark yes, no, or don’t know/understand (dk/u).

     

    MEDICAL HISTORY

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  • ALLERGIES

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  • DENTAL HISTORY

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  • PATIENT HEALTH INFORMATION

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  • RELEASE AND WAIVER

    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 history.

    I authorize release of any information regarding my orthodontic treatment to my dental insurance company. As a condition of treatment by this office, I understand financial arrangements must be made in advance. I authorize and understand a complete examination to develop an orthodontic treatment plan sometimes includes x-rays, photographs, and study models. I have read the above conditions and agree to their content.

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