What are the main concerns you would like an orthodontist to accomplish?
Have you visited an orthodontist before? If so, when and why?
Are you currently being treated by a physician? If yes, please include your physician's name, number, reason for treatment, and most recent treatment date.
Do you have any allergies or sensitivities to medications or latex? If yes, please list all allergies.
Are you currently taking any prescription or over-the-counter medications? If yes, please list with dosage.
Have you had any serious illness or operations? If yes, please describe.
How did you hear about us?