braces in cary nc

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Patient Information

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Responsible Party Information

Dental Insurance

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Person To Contact In Case of an Emergency

Dental History

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Please briefly answer/describe any of the following which apply to you.

Previous orthodontic treatment
History of dental/ facial trauma?
Broken/Missing teeth?
Jaw/Joint problems?
Locking, clicking, grinding, popping?
Do you have any type of thumb or tongue habit?

Financial Expectations

To help meet your expectations, we ask that you fill out this portion so we can customize your treatment options. Investing in a smile is one of the best choices you can make!
If treatment is recommended for you/your child, what is your ideal down payment?
If treatment is recommended for you/your child, what is your ideal monthly payment?
If treatment is recommended for you/your child, what is your desired time frame to begin this exciting journey?

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential. Please check any of the following which apply to you, and add any relevant comments.
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Are you taking any medications?
List any history of serious illness, accident, or other conditions
For Females only: Are you currently Pregnant?

Please check any of the following that you have had or currently have:

Artificial Joint Replacement/Implant
Abnormal Bleeding/Hemophilia
Anemia
Arthiritis
Asthma or Hay Fever
Bone Disorders
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Hepatitis/Liver Problems
High Blood Pressure
HIV/AIDS
Kidney Problems
Latex Allergy
Nervous Disorders
Radiation/Chemotherapy
Tumor or Cancer
Tuberculosis
Are there any medical conditions we have not discussed that you feel we should be aware of?
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