Date of Birth:
Age: Sex: Male Female
Name of other family members treated by our office:
How did you hear about our office:
Dentist’s Name: Physician’s Name:
I have provided the above dental and medical information, reviewed it and find it accurate. If there are any changes to this history record, I will so inform this practice. I also give my authorization for an orthodontic examination to be performed. I authorize Dr. Darryl Smith to use and disclose information contained in my dental records to my dentist, family physician and other dental / medical specialist and to my insurance company and its agents / contractors with respect to myself (and / or my children’s orthodontic treatment). This information could include (but is not limited to) things such as name, address, phone number, gender, date of birth, insurance information, employer, health and / or dental records. I understand that this information is collected to provide me and my family with safe and efficient care. I also understand that this office endeavors to ensure that personal information is accurate, up to date and protected. I also acknowledge, where applicable, that it is my responsibility to inform you of any changes in my / my child’s medical status. I further acknowledge that, during the course of treatment, you will continue to discuss treatment details regarding my child with the responsible party UNLESS we choose to notify you otherwise, in writing, when my child turns 18.
I have read the consent agreement and agree.