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PATIENT INFORMATION
Street, City, State, Zip Code
Street, City, State, Zip Code
PARENT/GUARDIAN INFORMATION
Street, City, State, Zip Code
Street, City, State, Zip Code
DENTAL INSURANCE INFORMATION
Primary Insurance
Street, City, State, Zip Code
Secondary Insurance (if applicable)
Street, City, State, Zip Code
Medical History
DENTAL HISTORY
RELEASE AND WAIVER

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 child’s medical or dental health.

Parent/Guardian Signature:

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

Parent/Guardian Signature: