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Invisalign Consultation

Supplemental Medical Information

Please read and sign the form below.

(Required prior to placement)

YOUTH & FAMILY HEALTH HISTORY

Youth's DOB

Which of the following diseases has the child had?

Mumps

Pneumonia

Diabetes

Asthma

Whooping Cough

Heart Trouble

Sickle Cell

Rheumatic Fever

Scarlet Fever

Measles

Tuberculosis

Convulsions

Chicken Pox

Other

Additional Notes on Above

Give dates and nature of any serious injuries and/or hospitalizations:

Doctor Name

Doctor's Address

Dentist Name

Dentist's Address

Hospitalization of immediate family members for injury or illness (including physical, mental, and/or emotional)

Completed by

Relationship:

Legal Custodian/Guardian Signature

Today's Date

© 2022 by Coastline Design.

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PO Box 21283

St. Simons Is, GA 31522

OPENING HOURS

At Home staff members are in the office and available most weekdays.

MONDAY - FRIDAY

07:00 AM - 08:30 PM

ADDRESS

TEL

912-223-8023

866-ENDHTGA (363-4842)

ENDHTGA.org

GA Human Trafficking Hotline

Stay in Touch!

TEXT MESSAGE

(877)448-7403

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