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  • CONFIDENTIAL

    Medical Dental History Form for Adult Patients

  • PATIENT

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  • CLOSEST RELATIVE


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  • DENTIST

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  • Other dentists/dental specialists now being seen

  • PHYSICIAN

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  • Other physicians/health care providers being seen now

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  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

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  • DENTAL INSURANCE

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  • MEDICAL INSURANCE

  • 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)

  • MEDICAL HISTORY

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  • DENTAL HISTORY

    Now or in the past, have you had

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  • PATIENT HEALTH INFORMATION

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  • WOMEN

  • FAMILY MEDICAL HISTORY

    Have your 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 orthodontic treatment to my dental and/or medical insurance company.

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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 medical or dental health.

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  • MEDICAL HISTORY UPDATES OR CHANGES

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  • Please also fill out our auto-pay authorization form located here

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