Dental Referral Form

Medical History Form (Adult)

Fill in necessary information below.
  • Close Relative

  • Dentist

  • Physician

  • Other physicians/health care providers being seen now

  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITIES

  • DENTAL INSURANCE

  • MEDICAL INSURANCE

  • Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions mark yes, no or don't know/understand(dk/u).

  • MEDICAL HISTORY

  • DENTAL HISTORY

  • Have you had allergies or reactions to any of the following:

  • PATIENT HEALTH INFORMATION

  • List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

  • FAMILY MEDICAL HISTORY

  • Have your parents or siblings ever had any of the following health problems? If so, please explain.

  • RELEASE AND WAIVER

  • I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

  • I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.

  • MEDICAL HISTORY UPDATES OR CHANGES