BIGGS-HANSEN ORTHODONTICS

www.indyortho.com
Jeffery Biggs, DDS, MS Vincent Hansen, DMD, MSD
9333 North Meridian Street, Suite 301, Indianapolis, IN 46260
Phone #: (317) 846-1455 E-mail: braces@indyortho.com Fax #: (317) 843-0626

Child's Clinical History/Family Information
Father's Information
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Mother's Information
Please upload pictures of your dental insurance card if applicable:
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MEDICAL HISTORY: 
Has the patient had or does the patient have any of the following?
DENTAL HISTORY
Does the patient have any of the following habits?
I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.