PATIENT INFORMATION

PRIMARY LEGAL GUARDIAN/RESPONSIBLE PARTY

SECONDARY LEGAL GUARDIAN

PRIMARY ORTHODONTIC INSURANCE

SECONDARY ORTHODONTIC INSURANCE

EMERGENCY CONTACT INFORMATION

DENTIST AND PHYSICIAN INFORMATION

MEDICAL HISTORY

HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES OR MEDICAL PROBLEMS?

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

DENTAL HISTORY

Does the patient have any of the following habits:

Medical History Update

Parent /Guardian Signature
Date
Parent /Guardian Signature
Date
Parent /Guardian Signature
Date