PATIENT INFORMATION

If Patient is a child:

PRIMARY RESPONSIBLE PARTY INFORMATION

 
 
 

SECONDARY RESPONSIBLE PARTY INFORMATION

 
 
 

PATIENT DENTAL HISTORY

Check (Yes | No) if you/your child experienced the following:

BAD BREATH BLEEDING GUMS JAW CLICKING
SENSITIVITY TO COLD SENSITIVITY TO HOT FOOD COLLECTING BETWEEN TEETH
SENSITIVITY TO SWEETS LOOSE/BROKEN TEETH GRINDING/CLENCHING TEETH
SORES IN MOUTH MOUTH BREATHING PERIODONTAL TREATMENT
SNORING NAIL BITING THUMB/FINGER SUCKING

MEDICAL HISTORY

Check (Yes | No) whether you/your child have/has/had any of the following:

AIDS/HIV+ HEPATITIS HIGH BLOOD PRESSURE
DIABETES KIDNEY DISEASE HEART MURMUR
LIVER DISEASE HEMOPHILIA HEART ATTACK
JAW PAIN EPILEPSY CONGENITAL HEART DEFECT
SINUSES TUBERCULOSIS DRUG/ALCOHOL ABUSE
COLD SORES RHEUM FEVER MITRAL VALVE PROLAPSE

ALLERGIC TO LATEX?

I understand the information that I have given is correct to the best of my knowledge and that it will be held in the strictest of confidence. It is my responsibility to inform this office of any changes in my/my child’s medical status. I also authorize the orthodontic staff to perform the necessary orthodontic services I/my child may need.

I have also read, understand and have been offered a copy of the HIPAA consent form.

The parent/guardian/patient present is responsible for payment at the time of service unless prior arrangements have been approved