Gender

Residence
Has the patient ever been in this office before?
Has any other member of your family had orthodontic care at this office?
Did he/she refer you to our office?

Does the patient have or has he/she ever had:
Anemia
Diabetes
Epilepsy
Hepatitis
Asthma
HIV+/AIDS
Rheumatic Fever
Heart Murmur
Abnormal Blood Pressure
Abnormal Bleeding From A Wound
Other
Allergies to:
Penicillin
Local Anesthetic
Other


Is the patient a minor?
Mother:
Father:
Spouse/Other?
Spouse/Other:
Do you have dental insurance that may cover any part of orthodontic sevices?
Or
If more than one insurance, is this one:

By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health. I authorize the dental staff to perform necessary dental services that I, or my child, may need during diagnosis and treatment.