Health History - Adult

About You

Closest Relative

Patient's dentist

Patient's physician

Financial Responsibility

Dental Insurance

Front Image Needed

Back Image Needed

Orthodontic History

  • (1) Not important
  • (2) Somewhat important
  • (3) Important
  • (4) Very important
  • (5) Extremely important

Dental History

Medical History



Other Health Information

Release and Waiver

Clear
Clear