Orthodontics for Children and Adults
1063 W Northwest Blvd
Winston-Salem, NC 27101
Phone: 336-725-5757
Fax: 336-354-4477

Medical History Form

Medical Forms The medical forms for Children are for those ages 0-17 years old. These forms are to be completed by the child’s parent or guardian and include consent for treatment. If you are under Medicaid insurance, please have a referral from your general dentist, with all needed treatment of cavities completed prior to our initial consult

PDF Medcial history form – Child

Our medical forms for Adults should be completed by anyone 18 years of age or older. If you have not had a dental appointment with your regular dentist in the last year, we request that you complete a general dental exam and cleaning prior to your initial
orthodontic consultation.

PDF Medical history form – Adult

If you are unable to read or speak English, we do have Spanish-speaking interpreters available at the office to assist you with the forms.



Salem Smiles Orthodontics
1063 W Northwest Blvd
Winston-Salem, NC 27101
P: (336) 725-5757


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