Confidential Patient Information

* First Name:

Middle Initial:

* Last Name:

Is there anything that you wish us to know regarding the above patient?

I certify that no changes have been made to the patient’s health history.

I certify that no changes have been made to the patient’s dental insurance coverage.

I certify that I have read and understand the above information. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.

* Parent/Guardian Signature:

* Parent/Guardian Print Name:

* Relationship to Patient:

* Date: