Kozlowski Orthodontics

Confidential Patient Information for Mouth Guard Program

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Confidential Medical & Dental History

Please answer the following questions about your child’s history:

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform this office of any changes in my child’s medical status.

Signature of Parent or Guardian

By completing this form you agree to receive the occasional email from Kozlowski Orthodontics regarding the latest information on promotions and other happenings in the Koz world.