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Health History Form

Please take a few minutes to fill out this confidential form, click the “Submit Form” button at the bottom, and your information will be sent to our office with secure encryption. Thank you!

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Patient Form

Items marked with asterisk (*) must be completed.

M/F
Text Consent

If patient is a minor, list all that apply:

Text reminders?
Father's Text Reminders
Step Mother's Text Reminders
Step Father's Text Reminders
Other Guardian's Text Reminders
I consent to receive SMS text messages from LeMert Orthodontics to all cell phones listed unless indicated in the next field. Msg&data rates may apply. Reply STOP to opt out.

Consumer information is not shared with third-parties for marketing purposes.

Dental History

Have you ever had an orthodontic consultation?
Have you had braces or any orthodontic treatment?
Do you avoid brushing any part of your mouth because of pain?
Do you chew on only one side of your mouth?
Do you clench or grind your jaws while sleeping or during the day?
Do your jaws ever feel tired?
Do your jaws "click", "pop" or "grate" when opening or closing?
Do you have frequent headaches, neck or back pain?
Do you gag easily?

Medical History

General Health (please check):
Are you taking any medication?

Have you ever been treated for: 

Abnormal blood pressure
Anemia
Arthritis
Asthma or Hay fever
Osteoperosis
Congenital Heart Lesions
Diabetes
Epilepsy
Heart Murmur
Hepatitis/Liver Problems
Exposed to A.I.D.S. Virus?
Prolonged Bleeding
Rheumatic Fever
Tuberculosis or Lung Disease
Heart Disease
Sinus Trouble
Stroke
Subject to Fainting Spells?
Have you ever taken any Bisphosponates for Osteoporosis?
Please check what you are allergic to:
Women: Are you pregnant?

Consent

I consent to having radiographs and photographs for diagnostic purposes.

Dental Insurance Information

If you have dual coverage please complete:

Responsible Party Information

Emergency Contact

Acknowledgement of Receipt of Notice of Privacy Practices

**You may refuse to sign this acknowledgement**

We may disclose your health information to a family member, personal representative, friend or other person to the extent necessary to help with your healthcare, but only if you agree that we may do so. Please list the individuals below who have your permission to share your health information:

Sign and Submit

By typing my name below, I certify that the above information is correct and accurate to the best of my knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

southwestern oregon orthodontic
Roseburg
1729 W Harvard Ave, Suite 3
Roseburg, OR 97471
info@lemertorthodontics.com (541) 673-0924

Hours

Mon – Fri: 7:45am – 4:30pm
Sat & Sun: Closed
*Lunch from 12:30pm-1:30pm
Coos Bay/North Bend
375 Park Ave, #7
Coos Bay, OR 97420
info@lemertorthodontics.com (541) 267-3060

Hours

Mon – Thurs: 7:45am – 4:30pm
Fri – Sun: Closed
*Lunch from 12:30pm-1:30pm