MEDICAL DENTAL HISTORY FORM FOR PATIENTS UNDER AGE 18

CONFIDENTIAL

Patient
Today's Date:
Birth Date:
Parent / Guardian
Patient lives with:
Title: Mr.Dr.Other
Title: Mrs.Ms.Dr.Other
Dentist
General Information
Had ortho treatment? YesNo
Had ortho treatment? YesNo
Had ortho treatment? YesNo
Had ortho treatment? YesNo
Financial Responsability
Dental/Orthodontic Insurance
Birth Date:
Does this policy have orthodontic benefits? YesNoDo not Know
Birth Date:
Does this policy have orthodontic benefits? YesNoDo not Know
Patient Health Information
Medical History:
Check All That Apply
Allergic Reactions:
Check All That Apply
Dental History:
Check All That Apply
WOMEN ONLY:
Release and Waiver
By checking this box, I authorize release of any information regarding my 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 any member of his/her staff responsible for any error or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Date: