Your kindness in furnishing the following information will be appreciated in preparing your child’s clinical chart.
Does your child have or has he/she had any of the following:
Is your child allergic to or has he/she had any unusual reactions to:
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.
4721 Chamblee Dunwoody Rd., Suite 200Dunwoody, GA 30338
3796 Satellite Blvd., Suite 200Duluth, GA 30096
500 Concord Rd. SESmyrna, GA 30082