Child New Patient Form

* required field

Patient Information

Gender






Primary Phone Number




Parent/Guardian Information

Parent Marital Status
Relationship







Phone Number
Secondary Phone Number

Relationship







Phone
Secondary Phone Number

Emergency Contact








Insurance Information



























Dental History

How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?

Has your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child you have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits?





Medical History

Is your child currently being treated by a physician?



Does your child currently have or ever been diagnosed with:
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe
Has your child ever had a blood transfusion?





Check if your child has or have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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