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.


Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.
Kirby's Kash Kirby Nelson Orthodontics Kirby's Kash Kirby Nelson Orthodontics

Be part of the fun by tracking and redeeming your rewards points.

Learn More...
Seattle Met

Voted
Top Orthodontist
7 years running
2011-2017
Seattle Met

Learn More...