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  • CONFIDENTIAL

    Medical Dental History Form for Patients Under Age 18

  • PATIENT

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  • PARENT/GUARDIAN


  • Mother Information


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  • Father Information


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  • DENTIST

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  • Other dentists/dental specialists now being seen

  • GENERAL INFORMATION

  • List Brother / Sister 

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  • FINANCIAL RESPONSIBILITY

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  • DENTAL INSURANCE

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  • MEDICAL INSURANCE

  • PHYSICIAN

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  • Other physicians/health care providers being seen now

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  • Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, mark yes, no, or don’t know/understand (dk/u

  • PATIENT HEALTH INFORMATION

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  • MEDICAL HISTORY

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  • DENTAL HISTORY

    Now or in the past, has the patient had:

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  • FAMILY MEDICAL HISTORY

    Have the parents or siblings ever had any of the following health problems? If so, please explain.

  • RELEASE AND WAIVER

    I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company

  • Clear
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  • 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 errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

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  • MEDICAL HISTORY UPDATES

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  • Clear
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  • Clear
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  • Clear
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  • Should be Empty: