• Adult Medical History Form

  • Patient Information

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  • Orthodontic Insurance Information

  • Primary Insurance

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    • Click here for Secondary Insurance 
    • Secondary Insurance

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  • Emergency Information

  • Medical History

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  • Please answer all the questions below:

  • Dental History

  • I have read and understand the before and above questions. I will not hold Get It Straight Orthodontics & Family Dentistry or any staff responsible for any errors or omissions that I have made in completion of this form. If there are any changes to this history record or medical/dental status, I will so inform this practice.

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  • Should be Empty: