Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Now or in the past, have you had:
Yes No DK/U
Have you had allergies or reactions to any of the following?
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.