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 St
Mobile, AL 36607
801 S University Blvd Building B-2
Mobile, AL 36609
1059 Snow Road South, Building A,
Mobile, AL 36695