Mother, Father, Aunt, Uncle Grandparent etc.
Any other person that may accompany your child to their visit
(This may be a different company than your child's medical insurance)
This could be the subscriber's social security number if you didn't receive a dental insurance card.

MEDICAL HISTORY

FOR THE FOLLOWING QUESTIONS YOU ONLY NEED TO CLICK IF THE ANSWER IS YES. PLEASE PROVIDE DETAILS AT THE END OF THE SECTION FOR ANY POSITIVE RESPONSES.

DENTAL HISTORY
Ages 5 and under only
If yes, please describe and list name of treating orthodontist