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Patient Information

   



        


Parent or Neighbor (alternate contact person)








Medical History

Does the patient have a history of (check all that apply):

 

 

Yes No 
27) Have you had any serious illness, operation, or hospitalization?
28) Are you taking any drugs or medications?
29) (Female only) Are you pregnant?

Dental History

Yes No 
31) Have any other members of the family had orthodontic treatment?
32) Does any member of the family have similar arrangement of the teeth?
33) Do you have a history of thumbsucking?
34) Do you have a history of lip or cheek biting?
35) Do you have a history of chronic mouth breathing?
36) Do you have a history of grinding or clenching the teeth?

Please elaborate on any checked items:

Number Description or Explaination

 


Ortho Insurance





As a courtesy to our patients, we will submit any necessary insurance claims provided that we have been informed of the current insurance coverage and have all necessary information needed to process the clain The patient will be responsible for any uncovered portion.

Signature for insurance release, insurance payment authorization and examination consent need to be signed in our office at the time of your first visit appointment.