Adult Medical History Form

Please Check All That Apply


Realizing that successful treatment greatly depends upon the patients complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment? I have read and understand the above questions. I will not hold my orthodontist 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 so inform this practice.


Be sure to bring the printed form with you on your first visit.