Patient Information Statement Form

You can download the form in pdf here.

Dental

&Medical History

No. 

General information

Patient’s name 
Birthdate  
Address 
Postal code 
Tel. 
Mobile 
E-mail 
Occupation  
Mother's name (for children)  
Occupation 
Mobile 
Father’s name (for children)  
Occupation 
Mobile 
Mother’s email  
Father’s email 
Spouse’s name (for adults) 
Spouse’s Occupation  
Mobile 
Marital Status: 
Who referred you to our clinic?  
Reason for asking treatment:  

Dental History

Patient’s Dentist 
Does the patient (now or at previous time):
YES
NO
YES
NO
Grind the teeth?/span>
YESNO
Had any surgery on the face or jaws?
YESNO
Chew or suck on the fingers or lips?
YESNO
Have speech problems?
YESNO
Fallen on the face?
YESNO
Have frequent headaches ?
YESNO
Problem with adenoids?
YESNO
Breath through the mouth ?
YESNO
Problem with tonsils?
YESNO
Had any injuries to the jaws or teeth?
YESNO
Have difficulty in cleaning the teeth ?
YESNO
Have any pain in the face?
YESNO
Noticed any clicking near the ears?
YESNO
Problem with dental treatment ?
YESNO

Medical history

Patients Physician/Pediatrician 
Heart diseases 
Infectious diseases 
Other diseases 
Retardation  
Blood diseases 
Endocrine disturbances  
Allergies  
 
 
Have you taken any steroids for the last two years?
Name any medications the patient is currently taking.
Other conditions your orthodontist should know about.
Is the patient under a physician’s care for any reason?

I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. I understand that this information will be held in strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I hereby authorize the release of all medical records on the above named patient to the referring dentist, physician or other health care provider, as well as information and records necessary for processing insurance claims. I authorize the release of financial information for collection and records transfer purposes. I authorize the necessary diagnostic tests and any orthodontic treatment deemed necessary to be performed by or under the direction of Dr. Laspos and/or associates of Laspos Orthodontic Center. I give my permission for any photographs, x-rays or study models to be updated during treatment and to be used for displays in our office, on our website, at scientific meetings, presentations and publications of a scientific nature or for study group purposes to further the art and science of orthodontics.

 

I authorize Laspos Orthodontic Center to communicate with me by using the contact details I have provided in this form.

Signature (parent for children)
 
Date
THE ABOVE INFORMATION REMAIN PRIVATE


I confirm that I have read, understand and agree to the above policy and procedure for the keeping and processing of my personal data

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Full Name
Telephone
Email
Address
Preferred Date
Preferred Time
Full Name
Telephone
Email
Address
Preferred Date
Preferred Time
Full Name
Telephone
Email
Address
Preferred Date
Preferred Time