Other dentists/dental specialists now being seen:
Other physicians/health care providers being seen now:
Have you had allergies or reactions to any of the following:
Now or in the past, have you had:
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride
supplements that you take.
Have your parents or siblings ever had any of the following health problems? If so, please explain.
I authorize release of any information regarding my 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
medical or dental health.
58 Mobile Street N.
Mobile, AL 36607
801 S. University Boulevard
Mobile, AL 36609
1059 Snow Road S.
Mobile, AL 36695