Falsafi Ortho Child Form

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Unusual dental problems

Other family medical conditions?

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 childs medical or dental health.

MEDICAL HISTORY UPDATES

Changes

Parent/Guardian Signature

Date:

Dental Staff Signature

Date:

Changes

Parent/Guardian Signature

Date:

Dental Staff Signature

Date:

Changes

Parent/Guardian Signature

Date:

Dental Staff Signature

Date:

CONFIDENTIAL

Medical Dental History Form for Patients Under Age 18

PATIENT

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand (dk/u).

PATIENT HEALTH INFORMATION

MEDICAL HISTORY

MEDICAL HISTORY continued

Has your child had allergies or reactions to any of the following?

DENTAL HISTORY

Now or in the past, has the patient had:

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

MEDICAL HISTORY UPDATES