Kirby's Kash Kirby Nelson Orthodontics Kirby's Kash Kirby Nelson Orthodontics

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Seattle Met

Voted
Top Orthodontist
7 years running
2011-2017
Seattle Met

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Patient Information
Medical/Dental History
Does patient have any illness or physical condition we should know about?: Yes No
Has patient been to a physician in the last 6 months?: Yes No
Has patient been to a dentist in the last 6 months?: Yes No
Have any teeth (including "baby teeth") ever been extracted by your dentist?: Yes No
Have any permanent teeth ever been injured or loosened by a fall?: Yes No
Are any of the following conditions present in patient's present or past history:
If patient is a minor, please answer the following questions:
Any noticeable difficulty in breathing through the nose?: Yes No
Does the patient have speech problems?: Yes No
Has patient had speech or tongue therapy?: Yes No
Has thumb sucking been a habit after the age of 6?: Yes No
Has tongue thrust been a habit after the age of 6?: Yes No
Has mouth breathing been a habit after the age of 6?: Yes No
Responsible Party Information(Same as Patient)
If patient is a minor please fill out the following:


Contractual financial arrangements for service fees will be subject to approval of credit and may require a credit report.


Dental Insurance Information
 
Do you have secondary dental insurance? Yes No
 
HIPAA

I acknowledge that I have received the Statement of Privacy Practices for the offices of Kirby Nelson Orthodontics.


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