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
Mobile, AL 36609
1059 Snow Road S.
Mobile, AL 36695