MEDICAL HISTORY (Adult)

(to be answered by the patient; if you answer with yes, please explain)

Have you ever experienced one or more of the following medical problems:

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The information given today will be held in the strictest confidence and is to the best of my knowledge. It is my responsibility to inform this office of any changes in my medical status. I authorise my health care provider to release any information, including the diagnosis and records of treatment or any examination rendered to me, to other health practitioners in relation to the orthodontic treatment. My anonymised diagnostic records may be used for educational or promotional purposes.

For further information about how we use your data, please see our privacy policy.