For the following questions check yes or no. The answers are for the office records only and will be considered confidential. A complete history is vital to proper orthodontic evaluation. For any question answered "yes" please detail below.
I have read and understand the above questions. I will not withhold my orthodontist(s) or an member of their staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes in my medical or dental history I will inform this practice immediately.