Other dentists/dental specialists now being seen:
Other physicians/health care providers being seen now:
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic
evaluation. For the following questions, mark yes, no, or don’t know/understand (dk/u).
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride
supplements that your child takes.
Has your child had allergies or reactions to any of the
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..
58 Mobile Street N. Mobile, AL 36607
801 S. University Boulevard Building B-2 Mobile, AL 36609
1059 Snow Road S. Building A Mobile, AL 36695