Logo
Patient Information for O'Grady Orthodontics
If patient is an adult, please fill out information below
Street
City
State
Zip
If patient is a minor, please fill out information below
Street
City
State
Zip
Street
City
State
Zip
Medical History for O'Grady Orthodontics
In the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential
Women
Girls
Boys

I certify that I have read and understand the above. I acknowledge that any questions I have about the inquires set forth above have been answered to my satisfaction.

Signature of patient/parent or guardian