Check if Address Same as Above Address
Check if yes have insurance
Now or in the past, has the patient had:
Attention Deficit DisorderAllergy to LatexArthritisBehavioral problemsBirth Defects or Hereditary ProblemsBone or Joint DisorderDiabetesEpilepsy or ConvulsionsFainting or DizzinessFrequent Headaches or MigrainesGagging or nausea problemsGrowth or Endocrine ConditionHearing DisorderHeart DisorderPsychiatric Treatment or Psychological Disorder
I have read and understand the above questions. 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. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
Patient/Legal Guardian Electronic Signature:
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