Patient Health History Information - Potter Orthodontics

Confidential Youth Patient Health History & Information

  • Patient Information
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  • Responsible Party Information
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  • Insurance Information
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  • Dental History
  • Dental History
  • Genetic History
  • I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
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