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Patient Information

   



        











Grandparent or Neighbor (alternate contact person)





Medical History

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

 

 

Yes No 
27) Has the patient had any serious illness, operation, or hospitalization?
28) Is the patient taking any drugs or medications?
29) (Female only) Is the patient 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) Does the patient have a history of thumbsucking?
34) Does the patient have a history of lip or cheek biting?
35) Does the patient have a history of chronic mouth breathing?
36) Does the patient have a history of grinding or clenching the teeth?

Growth History

37) Does any member of the family have a significant underbite or prominent lower jaw?
38) (female only) Has the patient started her monthly perious?   
39) Is the patient maturing

   
   

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.