Utah Orthodontic Care/
801.999.4431

New Patient Online Form

New Patient Information

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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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 Yes No

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

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

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 Aspirin Penicillin or other antibiotics Latex(gloves, balloons) Vinyl, Acrylic or Animals Ibuprofen(Motrin, Advil) Tylenol Sulfa Drugs Metals (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.

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