Form – Medical and Dental History for Patients

Patient Information

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, please mark yes, no, or don’t know/understand (DK/U).

Medical History

Now or in the past, have you / has your child had:

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

Dental History

Now or in the past, have you / has your child had:

Patient Health Information

Family Medical History

RELEASE AND WAIVER

I authorize release of any information regarding 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 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.