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Adult History Form

Office Location

LondonSt. thomas

Patient Information

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Address

Medical History

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Anticipated due date:
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YesNo Rheumatic Fever
YesNo Heart Murmur
YesNo Heart Valve Disease
YesNo Heart Attack / Stroke
YesNo Prosthetic Joint / Valve
YesNo High/ Low Blood Pressure
YesNo Hemophilia
YesNo Blood Disorder
YesNo Infectious
YesNo HIV/ AIDS
YesNo Hepatitis
YesNo Mental Health Problems
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YesNo Kidney Disease
YesNo Thyroid Disease
YesNo Liver Disease
YesNo Asthma
YesNo Tuberculosis (TB)
YesNo Cancer/ Radiation therapy
YesNo Lung Disease
YesNo Diabetes
YesNo Stomach Ulcers
YesNo Herpes (any type)
YesNo Skin disease (e.g. Eczema)
YesNo Persistent Headaches / Migraines
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YesNo Never or Brain Disease
YesNo Seizures / Epilepsy
YesNo Autism
YesNo Arthritis
YesNo Bone Disorders
YesNo Neck Pain
YesNo Vision or Hearing Problems
YesNo Sleep Apnea
YesNo Sinus Problems
YesNo Allergies
YesNo Other

Dental History

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Insurance Information

Our office bills the Patient or Responsible Party directly for all services rendered. You will be provided with a Standard Information Form to submit to your carrier to determine the amount of orthodontic coverage to which you are entitled. We are also happy to answer any questions or provide any assistance you require to make the insurance process as smooth as possible.

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Take your smile to the next level!

We are here to help. Schedule a Consultation now!

Two convenient locations to serve you

LONDON OFFICE

218 Commissioner's Rd. W London, Ontario N6J 1Y1

(519) 685-3060

admin@marcycurranortho.com

ST. THOMAS OFFICE

291 Talbot Street St. Thomas, Ontario N5P 1B5

(519) 207-3061

info@marcyorthodontics.ca