Parent’s Marital Status: Single Married Separated Divorced Widowed
Patient lives with: Parents Father Mother Guardian
Name and Ages of Other Children in the Family
Has anyone in your immediate family had orthodontic treatment with us?
If so, who?
Is there anyone else that would like to be seen by us today?
Relationship to you
Last dental cleaning:
Date of next cleaning:
WHO WILL BE FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT?