Lakeshore Orthodontics is dedicated to providing your family with the very best orthodontic care in a supportive and caring manner. We believe our office should be a friendly, welcoming environment that patients enjoy visiting. Due to the Covid-19 outbreak and the severity of the situation, we feel it is necessary to make changes to ensure the safety of our patients and team. The office may appear different, but our mission remains the same.

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Medical Dental History Form

Patient

Closest Relative

Dentist

Other dentists/dental specialists now being seen:

Physician

Other physicians/health care providers being seen now:

General Information

Financial Responsibility

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, please mark yes, no, or don’t know/understand (dk/u).

Medical History

Now or in the past, have you had:

Have you had allergies or reactions to any of the following?

Dental History

Now or in the past, have you had:

Patient Health Information

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

Family Medical History

Release and Waiver

Patient

Parent/Guardian

General Information

Dentist

Physician

Other physicians/health care providers being seen now:

Financial Responsibility

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, please mark yes, no, or don’t know/understand (dk/u).

Medical History

Now or in the past, has your child had:

Has your child had allergies or reactions to any of the following?

Dental History

Now or in the past, has your child had:

Patient Health Information

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

Family Medical History

Release and Waiver