New Patient Medical/Dental History

You may fill out the New Patient Medical/Dental History Form online and submit it to our office, or download, print, and fill out a PDF copy of the form to bring with you to your next appointment.

Download PDF – Medical/Dental History Form

Medical/Dental History Form

  • PATIENT

  • By providing a mobile number, I agree that Andros Orthodontics may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
  • PARENT/LEGAL GUARDIAN (if patient is a minor)

  • DENTIST

  • REFERRAL INFORMATION

  • GENERAL INFORMATION

  • PATIENT HEALTH HISTORY

  • MEDICAL/DENTAL HISTORY

    Now, or in the past, has the patient had:

  • RELEASE AND WAIVER

Call Us For Appointment

(509) 792-1008

Book Appointment Online

Book Appointment