Child Orthodontic Consultation form
Responsible party/insured
Nearest relative not in same household
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If so, please complete the following
Dental History
Have there been injuries to the face, mouth, or teeth?
Patient suck thumb or fingers?
Does the patient have speech problems?
Is the patient a mouth breather?
Have you been informed of any missing or extra permanent teeth?
Has an orthodontist been consulted previously?
Has either parent had orthodontic treatment?
Medical History
Please check any that the patient has had in the past or has currently
Has patient had tonsils or adnoids removed?
Is patient currently under the care of physician
Is patient taking (or supposed to be taking) any medications?
Does patient have allergies or reactions to drugs or medicines?
Has patient had a reaction to general or dental anesthetic?
Has patient ever had any operations or surgery?
Has patient ever been hospitalized?
If the patient is female, has she started menstruation?
Is the patient is male, has his voice changed?
have we treated this child before?
Have we treated this child before?
Have we treated this child before?
Have we treated this child before?

To the best of my knowledge, all of the preceding answers are true and correct. If patient ever has any changes is his or her health, abnormal laboratory tests, or if any medicines change, i will inform the dentist at the next available appointment without fail. 

As the responsible party , I authorize a credit report to be obtained for financial arrangements in Dr. Pryse's office.

Your Signature

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