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Meet Our Team(s)!
Dr. Tonya Baker
The Team Of Baker Orthodontics
Dr. Kelle Cox
The Team of Grins and Giggles
Orthodontics
Invisalign Preffered
Ceramic Braces
Speed Treatment
Comfort Braces
Retainers
Embrace It Program
Pediatric Dentistry
Why Baker?
Free Check Ups
Invisalign Preffered
Guarantees
Family Discounts
Payment Options
Reward Program
Community Involvement
Q.A.
Orthodontic Aquaintence Form
Date Of Birth:
Sex:
Male
Female
Allow Text Alerts?
Yes
No
Do you have orthodontic coverage on your dental insurance:
Yes
No
Last visit to dentist:
Relationship?
Former Patient
Family
Friend
Dentist
Yellow Pages
Radio
Tv
Newspaper
COMPLETE ONLY IF ABOVE IS A MINOR
Date Of Birth:
Date Of Birth:
Parent's are:
Married
Divorced
Separated
Widowed
COMPLETE ONLY IF ABOVE IS AN ADULT
Date Of Birth:
Date Of Birth:
MEDICAL HISTORY
Is the patient under the care of a physician for a specific problem at the present time?
Yes
No
PLEASE CHECK THE FOLLOWING AS THEY APPLY
AIDS
Allergies / asthma
Arthritis
Bleeding problems
Diabetes
Ear infections
Emotional problems
Endocrine problems
Epilepsy
Glaucoma
Head or facial injury
Hearing problems
Heart trouble
Hepatitis / liver disease
High blood pressure
Kidney problems
Nerve problems
Rheumatic fever
Tonsilitis
DENTAL HISTORY
Yes
No
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Has patient ever sucked thumb or finger?
Yes
No
Have you been informed of any missing or extra permanent teeth?
Yes
No
Has an orthodontist been consulted previously?
Yes
No
Has patient had any previous orthodontic treatment? If so, by whom
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