ADULT PATIENT INFORMATION FORM

TELL US ABOUT YOU

Last
First
MI

SPOUSE'S INFORMATION

EMERGENCY CONTACT INFORMATION

PERSON RESPONSIBLE ACCOUNT

Please list all medications that you are currently taking

Are you Allergic to any of the following?

Do you now have or have you had any of the following habits?

Do you now have or have you had any of the following?

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

We reserve the right to verify the credit status prior to extending credit for treatment.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.

I will not hold the orthodontist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. I understand that I am responsible for the payment of services rendered and for paying and co-payment and deductibles that my insurance does not cover.