Adult History Form

Office location * St. thomas

First Name *

Last Name *

Initial *

Help us call you by the proper pronoun * MaleFemaleNeutral

Best method to reach you

Home Tel

Cell

Work Tel

Can we contact you by text message? * YesNo

Address

Street *

City *

Postal Code *

Medical History

Family Physician *

Do you have or have you ever had any of the following?

Please list any other significant information about your medical history:

Dental History

What is your primary concern about your teeth and smile?

Family Dentist

Date of last check up

Any other information, you can give us is definitely appreciated. The more we know about each person, the more help we can give in managing the orthodontic treatment, both at home and in the office. I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognize that it is my responsibility to inform this office. I also give the permission for a clinical examination.

Signature of Patient

Date

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.

Do you have orthodontic coverage? YesNoDualUnsure

Take your smile to the next level!

We are here to help. Schedule a Consultation now!

ST. THOMAS OFFICE

291 Talbot Street St. Thomas, Ontario N5P 1B5

(519) 207-3061

info@marcyorthodontics.ca

Office Location

Patient Information

Address

Medical History

Dental History

Insurance Information

Take your smile to the next level!