Other dentists/dental specialists now being seen
Sibling name name age age
Have any other family members been treated in this office?
List any medications, nutritional supplements, herbal medications or non-prescription medicines, fluoride supplements your child takes.
Now or in the past has your child had:
Has your child had allergies or reactions to any of the following:
Now or in the past, has the patient had:
Have the parents or siblings ever had any of the following health problems? If so, please explain.
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.