Sudbury COMBINED Insurance Medical History Form

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Our Office Complies With Privacy Legislation, The Regulations Of The Royal College Of Dental Surgeons Of Ontario And The Law. Please Be Assured That Every Team Member In Our Office Is Committed To Protecting Your Personal Health Information. The Above Medical History Is Correct To The Best Of My Knowledge. I Authorize My Doctor To Consult With And/Or Send Reports And/Or Dental Practitioners As It Relates To Orthodontic Treatment.*

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Patient's Signature*
Patient's Full Name*

First NameMiddle NameLast Name
Responsible Party's Signature*
Responsible Party's Full Name*

First NameMiddle NameLast Name
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Child Medical History Form