What is the patients main orthodontic concern?
If any of the above dental questions were answered 'Yes', please explain:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
If any of the above medical questions were answered 'Yes' , please explain:
Please list the name and birthdate of any siblings:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment: