Orthodontic Patient Health History

Primary Parent Information
Primary Parent/Legal Guardian

First NameLast Name
Date of Birth

MonthDayYear
Relationship to Patient
Mailing Address (if different from patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Employer
Email
example@example.com
SSN
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Marital Status

SingleMarriedDivorcedWidowed
May the patient's information be released to the secondary and/or additional parent or legal guardian in the next section of this form?

YesNo

Acknowledgement of Forms
If this consent is signed by a personal representative/parent on behalf of the individual, complete the following:
Personal Representative's/Parent's Name

First NameLast Name
Relationship to Individual
To the best of my knowledge, all the information is complete and correct. I give permission for any photographs, x-rays, or study models to be taken for diagnosis purposes. I agree to be responsible for charges not covered by my dental benefit plan. I, the undersigned agree to pay attorney fees and other fees imposed by a 3rd party collector in the event it becomes necessary to use attorney services to secure payment of this account.*

Yes
Signature

Clear
We will not accept divorce decrees as assignments of responsibility for a minor’s orthodontic account. We require that the undersigned parent or legal guardian take full responsibility for all costs, and see reimbursement from other parties as needed.
Should be Empty: