Note: The fields indicated with an asterisk * are required fields.

CONFIDENTIAL
MEDICAL DENTAL HISTORY FORM

PATIENT INFORMATION

PATIENT’S DENTIST

PATIENT’S PHYSICIAN

GENERAL INFORMATION

DENTAL INSURANCE INFORMATION(if apply)

DENTAL AND MEDICAL HISTORY  (If yes, please fill in details)

Now or in the past, has patient had (medical):

Female Patients:

Now or in the past, has patient had (dental):

Have you had allergies or reactions to:

RELEASE AND WAIVER, 
I authorize release of any information regarding my orthodontic treatment to my dental insurance company.

I have read the above questions and understand them. I will not hold my orthodontist or any member of her staff responsible for any erros or omissions that I have made in the completion of this form.  I will notify deRoode Orthodontics of any changes in my medical or dental health.