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Frank Batastini Orthodontics

Specializing in Orthodontics for Children and Adults

(856) 262-0500
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Welcome to Frank Batastini Orthodontics!

Specializing in Orthodontics for Children and Adults
Making a Million Smiles, One Smile at a Time

Moorestown Turnersville Philadelphia

Adult Acquaintance

May 14, 2020 by drsail

Dr. Frank Batastini Orthodontics Adult Acquaintance Form

Adult Aquaintance

ADULT ORTHODONTIC ACQUAINTANCE CARD
  • General Information

  • MM slash DD slash YYYY
  • Medical History

  • Complete the Following Section

    Check Yes or No for each of the following for which the patient has been treated.
    Taking any prescription medication, supplements, herbal medications or non-prescription medications?
  • Enter approximate age that tonsils & adenoids were removed
  • Dental History

    Has there been any injuries to the face, mouth or teeth?
  • Please enter a number from 0 to 99.
    If answered yes to "Are you a mouth breather" Is this while awake or asleep or both?
  • I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice. I understand by checking this box and entering your name below, it acts as a signature for the Adult Orthodontic Acquaintance Card.
  • MM slash DD slash YYYY

Filed Under: Forms

AAOADAVirtuaNJDAInvisalignPennsylvania Dental AssociationPhiladelphia County Dental Society

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