Welcome to the Orthodontist

Welcome to Botsford Family Orthodontics

** Please complete both the front & back of this form, thank you! **
Patient Information
Todays Date

DayMonthYear
Date
MaleFemale
Your Child's Name*

LastFirstMI
Child's Birthdate

MonthDayYear
Child's Age
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Was the patient adopted?

YesNo
Father's Name

First NameLast Name
Father's Birthdate
Address (only if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Work/Cell Phone:

Area CodePhone Number
Father's Employer
Mother's Name

First NameLast Name
Mother's Birthdate
Address (only if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Work/Cell Phone:

Area CodePhone Number
Mother's Employer
Responsible Party of the Account:
School:
Grade
Whom may we thank for referring you to our office?
What is the main concern for your first to our office?
Dental Insurance Information
Primary Insured's Name:
Birthdate

MonthDayYear
Date
Socials Security #: (needed for verificaton)
Employer:
Dental Insurance Company:
Insurance Company Phone #

Area CodePhone Number
Member ID #:
Secondary Insured's Name:
Birthdate

MonthDayYear
Date
Social Security # (needed for verification)
Employer:
Dental Insurance Company:
Insurance Company Phone #

Area CodePhone Number
Member ID #:
Dental History
Your Child's Dentist:
Date of Last Cleaning:

MonthDayYear
Date
How often does your child brush?
How often does your child floss?
Has your child ever had any unusual dental problems? (please list):
Has your child ever had prior orthodontic treatment?

YesNo
If yes, what kind?
Have there been any injuries to the face, mouth, teeth or chin?*

YesNo
Has any other family member had orthodontics?
Medical History
Your Child's Physician
Phone Number

Area CodePhone Number
Date of Last Visit

MonthDayYear
Date
Medications your child is currently taking:
Currently under medical treatment for? If yes, please list:

Has your child ever had any of the following medical problems?

	Yes	No
Pain, clicking and/or popping noises in the jaw
Aware of either clenching or grinding of teeth
Ear Problems (Aches, ringing, dizziness, fullness)
Difficulty breathing through the nose
ADD/ADHD
Autism
Speech Problems? If your child in speech therapy?
Bleeds easily
Tendency to faint or become dizzy

	Yes	No
Hospital Stays
Any Operations
Cancer
Artificial bones/joints/valves
Heart Condition?
Does your child pre-medicate prior to dental procedures?
Has puberty begun?
Has menstruation begun? (Women only)

Current or history of habits such as nail biting, finger or thumb sucking, lip or cheek biting?

YesNo
Until what age?
History of (check all that apply):

Joint swellingAsthmaTBAIDSKidney conditionLiver ConditionEpilepsyRheumatic Fever
Name of your child's cardiologist?
Have you ever taken Fosamax, or any bisphosphonate?
Are there any other medical conditions that we should be aware of?

Are you allergic to any of the following?

	Yes	No
Aspirin
Any Metals/Plastics
Codeine or other narcotics
Dental Anesthetics

Are you allergic to any of the following?

	Yes	No
Penicillin or other antibiotics
Latex
Ibuprofen
Acrylic
Foods

Please list any other drugs/materials/foods that you are allergic to:
I understand that the information that I have given today is correct to the best of my knowledge. I will not hold my orthodontist or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Signature

Clear
Date
Should be Empty:

Welcome to Botsford Family Orthodontics

Patient Information

Dental Insurance Information

Dental History

Medical History