CONFIDENTIAL PATIENT INFORMATION


RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION


EMERGENCY CONTACT

HEALTH HISTORY

Have you had a history of any of the following?

FLOURIDE HISTORY

ORTHODONTIC HISTORY

For Patients Age 7 & Older

GROWTH & DEVELOPMENT DATA

AUTHORIZATION

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the orthodontist and pediatric dentist to help determine appropriate and helpful treatment. I also understand that if there is any change to my, or the above named patient’s dental or medical status, it is my responsibility to inform the doctor.


or

Be sure to bring the printed form with you on your first visit.