Welcome to Longmont Braces!
Please fill out this form completely. Thank you! About You
Name_________________________________ Preferred Name/Nickname_______________________________________________
Street Address_______________________________________________________________________________________________
City______________________ State ___________ Zip __________________Home Phone__________________________________
Birth Date____/____/____ Age________ Sex M F Employer_____________________________________________________
Day-Time Phone ______________Cell Phone ______________E-mail address ______________Spouse’s Name________________
How did you hear about our office? _______________________________________________________________________________
What is the reason you are seeking an orthodontic evaluation? _________________________________________________________
Has an orthodontist been consulted previously? Yes No Reason: _______________________________________________
Please list other family members seen in our office and their relation to you: _______________________________________________
Medical Health Information
Have you been hospitalized for any surgical procedure or serious illness? Yes No
Name of your physician_________________________________________________________________________________________
Do you have or have you had any of the following diseases or conditions? (Check all that apply.)______________________________
Yes No
Heart Defect, Heart Murmur, Heart Disease Do you or have you ever taken bisphosphonates, including Fosomax, Didronel, Boniva, Aredia, Actonel, Skelid, or Zometa?________
If so, which drug?________________________
Do you have any disease, condition, or problem not listed that you think we should know about? Please Explain:
Are you taking any medication at this time? Yes No If yes, Please list_____________________________________________
Dental Insurance Information
Primary Insurance Company Name
Do you participate in a flex plan? Yes No

Dental Health Information

Are you experiencing any Dental Problems Yes No Date of last dental visit___/___/____
How often do you brush and floss each day? Brush ___ times per day Floss ___ times per day
Dentist: _______________________________
Do you have or have you ever had any of the following problems?
Yes No
Tooth Sensitivity to Heat, Cold, or Sweets I acknowledge that the above information is correct. I will notify Longmont Braces of any changes that occur after this date. I hereby authorize Longmont Braces and its designees to perform an initial orthodontic evaluation/examination. Name:__________________________________ Date:_______________________

Source: http://www.longmontbraces.com/docs/health-history-adult.pdf


Hi ATSICS (A Tiny Shift In Connecting Schools) Members and Associate Members! 1.0 Membership for 2012-2013 I have updated our web page for members: Please see: http://atinyshift.ca/status.people.html Board: Please send me your current LONGER bio so that I can add it to this web page. If it contains any contact info, I will delete this before posting. 2.0 Income (Finances) Xmas was gene


Evidence based review of escitalopram in treating majordepressive disorder in primary careThomas R. EinarsonThe study aimed to summarize clinical data for43.5%, P = 0.003) but similar to venlafaxine-XR (P = 0.97). escitalopram in the treatment of major depressive disorderResponse rates were superior to placebo (48.7% versusin primary care. Medline, Embase and Cochrane databases43.1%, P <

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