Valencia

23838 W. Valencia Blvd., #300
Valencia, CA 91355

ORTHODONTICS ACQUAINTANCE CARD

IF YOU HAVE ORTHODONTICS INSURANCE, PLEASE COMPLETE INFORMATION BELOW:
DENTAL INSURANCE COMPANY #1
DENTAL INSURANCE COMPANY #2
DENTAL/MEDICAL HISTORY

Have you had any of the following medical conditions or problems?

PLEASE CHECK:
Heart Murmur
Hemophillia
Cancer
Heart problems of any kind
Bledding problems
Diabetes
Convulsions / Epilepsy
Hearing impairment
HIV + / AIDS
Hyperactive
Any operations
Rheumatic fever
Any stays in hospital
Glaucoma
Hepatitis
Latex Allergy
PLEASE CHECK:

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in strictest of confidence, and it is my responsibility to inform this office of any changes in my health status.