CONFIDENTIAL Medical – Dental History Form

Patient Information:

Medical History:

Have you / or has your child had allergies or reactions to any of the following?

Medications: Please list any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take / or your child takes.

Dental History:

Release and Waiver:

I authorize release of any information regarding me or my child’s 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 his/her staff responsible for any errors or omissions that I have made in completion of this form. I will notify my orthodontist of changes in my / my child’s medical or dental health.