Adult Form

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion? Yes No

If yes, give approximate dates:

If you have a history of a medical condition not listed above, please list/describe the condition:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I consent to Wilborn Orthodontics to taking any necessary diagnostic records, consisting of x-rays, photographs, and dental impressions in order to diagnos and formulate an orthodontic treatment plan.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date:

Security Measure

Adult Form

Patient Information

Spouse / Partner Information

Emergency Contact Information

Dental Insurance Information

Primary Dental Insurance Insurance

Secondary Dental Insurance

Dental History

Medical History

Authorization