Adult Health History

Patient Information

Your kindness in furnishing the following information will be appreciated in preparing your child’s clinical chart.

ADULT MEDICAL HISTORY

Have you ever had or presently have any of the following:

Are you allergic to or have you had any unusual reactions to:

Adult Dental History

I give my consent for the initial examination at no charge. If diagnostic records are needed to determine the necessity of orthodontic treatment, I give my consent and accept responsibility for payment of records which will include x-rays, study models and photographs

If printing form, please remember to bring completed form with you to your first visit.


we offer invisalign