I. Check Appropriate Answer

Medical Health History

The practice of orthodontics involves treating the whole person. If Dr. Schellinck determines that there may be a potentially medically-compromised situation, medical or dental consultation may be needed prior to commencement of orthodontic treatment. I authorize Schellinck Orthodontics to contact my physician or dentist if necessary. I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform Schellinck Orthodontics of any changes in my health and/or medications. I have reviewed my medical and dental health history and confirm that it accurately states past and present conditions.