New Patient Information

MF

Dental Insurance Information

If the patient is under 18 years old, please fill out this section if you are the parent or legal guardian of the patient.

Dental History
Now or in the past, have you had:

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Medical History
Now or in the past, have you had:

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AspirinPenicillin or other antibioticsLatex(gloves, balloons)Vinyl, Acrylic or AnimalsIbuprofen(Motrin, Advil)TylenolSulfa DrugsMetals (jewelry, nickel)Foods (specify)

I have read and understand the above questions. I will not hold my treating doctor 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 be sure to inform this practice. Furthermore, I consent to an orthodontic examination and if necessary, orthodontic records which include photos, impressions and x-rays.