Confidential Youth Patient Health History and Information for Sher Smiles Orthodontics
Please allow 15-20 minutes to complete this form in its entirety. Thank you!
Today's Date *
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We are excited to have you in our office! Whom may we thank for referring you?
Patient Information
Name *
Gender *
Patient's Nickname
Residence Address: Street *
Residence Address: City *
Residence Address: Zip Code
Birth date: *
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School
Grade
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