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