At Advanced Orthodontic Specialists we passionately believe that each and every patient should be treated uniquely with highly personalized care. Because of this, we ask you to please tell us what is important to YOU! We can then cater our process to make your experience even more fantastic. Please rate each of the following on a rating scale of 1-5, where 1 is ‘not at all important’ and 5 is ‘very important’.
PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE
DENTAL INSURANCE INFORMATION
Please circle Yes or No (If Yes, please fill in details)
Check any of the medical conditions below that you have had or currently have.
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Michael Bicknell to perform a complete orthodontic evaluation.