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Patient Information

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Person To Contact In Case of an Emergency

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential. Please check any of the following which apply to you, and add any relevant comments.
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Are you taking any medications?*
List any history of serious illness, accident, or other conditions*
For Females only: Are you currently Pregnant?*

Please check any of the following that you have had or currently have:

Artificial Joint Replacement/Implant*
Abnormal Bleeding/Hemophilia*
Anemia*
Arthiritis*
Asthma or Hay Fever*
Bone Disorders*
Diabetes*
Dizziness*
Epilepsy*
Gastrointestinal Disorders*
Heart Problems*
Hepatitis/Liver Problems*
High Blood Pressure*
HIV/AIDS*
Kidney Problems*
Latex Allergy*
Nervous Disorders*
Radiation/Chemotherapy*
Tumor or Cancer*
Tuberculosis*
Are there any medical conditions we have not discussed that you feel we should be aware of?*

Myobrace in Cary, NC

Myobrace is a preventive, pre-orthodontic treatment for children ages 5-15, some adults may qualify. This treatment can help avoid the need for braces in the future!

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