MEDICAL HISTORY (Child)

(to be answered by the parent, legal guardian or care-giver; if you answer with yes, please explain)

Has your child ever experienced one or more of the following medical problems:

If NO, please continue with this section:

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 child's medical status. I authorise my health care provider to release any information, including the diagnosis and records of treatment or any examination rendered to my child, to other health practitioners in relation to the orthodontic treatment. My child's 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.