Address: Springville 688 West 400 South, Ste 100 Springville, UT 84663 Phone: (801) 489-7878 Hours: Mon: 9:00 AM–5:00 PM Tue-Thrs: 8:00 AM–5:00 PM Fri: 8:00 AM-3:00 PM Contact Us
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Gender
Marital Status
Are you aware that some appointments will be during school/work hours
Responsible Party Marital Status
Dual Coverage
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Have you seen a physician in the last 12 months
Please mark any of the medical conditions you have had or currently have:
Have you had previous orthodontic treatment
If any of the dental questions are answered Yes, please explain
Are you presently in any dental pain
Have you ever experienced any unfavorable reaction to dentistry
ls any part of your mouth sensitive to temperature or pressure
Have there been any injuries to your face, mouth, or teeth
Do your gums bleed when you brush
Do you have any oral habits, such as tongue thrust or thumb sucking
Are you a mouth breather
Do your teeth or jaws ever feel uncomfortable when you wake up in the morning
Do you clench or grind your teeth
Do you have tension headaches
Has anyone in your family received orthodontic treatment? How did they feel about the result
Have you ever experienced chronic ringing in your ears
Are you pregnant
Has menstruation started
Benefits of orthodontics: aesthetics, health, and function
Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime, and there can be some movement of teeth and some change after treatment.
I have truthfully answered all of the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Warren to perform a complete orthodontic evaluation.
