New Patient Form

New Patient Form - Child
Patient's name*

First NameLast Name
Patient's date of birth*

MonthDayYear
Date
Parent/Guardian #1*

First NameLast Name
Parent/Guardian #1 address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address*
Is this person responsible for billing?*

YesNoOther
Is this the minor's primary address?

YesNoOther
Parent/Guardian #2

First NameLast Name
Parent/Guardian #2 address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
Is this person responsible for billing?*

YesNoOther
Is this the minor's primary address?*

YesNoOther
Please bill my PRIMARY insurance policy:

Yes
Please upload photos of the FRONT & BACK of PRIMARY insurance card (if applicable).*

Browse Files

Cancelof
Date of birth of PRIMARY card holder.*

MonthDayYear
Date
I would like to also use my SECONDARY insurance policy:

Yes
Please upload photos of the FRONT & BACK of SECONDARY insurance card (if applicable).*

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Cancelof
Date of birth of SECONDARY card holder.*

MonthDayYear
Date
I will be 'self pay'.*

YesNo
Referred by*
Current concerns*
Full Term Pregnancy?*
Type of Delivery*
Unexpected outcomes during the birth/delivery?
Birth weight*
Birth length*
Pass newborn hearing screening?*

YesNoUnsure
Pediatrician:*
Town Pediatrician is located:*
Dentist:
Please list the name and phone for any other medical professionals including, but not limited to the following: Orthodontist, Allergist, ENT, Occupational Therapy, Physical Therapy, Speech Pathologist, Chiropractor, Craniosacral Therapist
Any food or seasonal allergies?*
Feeding:*

Currently breastfedPreviously breastfedAttempted breastfeedingCurrently bottle fedSupplementing with bottlesPreviously bottle fedCurrently tube fed (G-tube or NG tube)Previously tube fed (G-tube or NG tube)Currently frustration when eatingPrevious frustration when eatingCurrent difficulty transitioning to solid foodsPrevious difficulty in transitioning to solid foodsCurrent slow eater (doesn’t finish meals)Previous slow eater (doesn’t finish meals)Currently grazes on food throughout the dayHistory of grazing on food throughout the dayCurrently packs food in cheeks like a chipmunkHistory of packing/holding food in cheeksCurrently pockets food in the mouthHistory of pocketing food in the mouthCurrently chokes or gags on foodHistory of choking/gagging on foodCurrently spits out foodHistory of spitting out foodCurrently won’t try new foodsHistory of caution when trying new foodsCurrently noisy eating/chewingHistory of noisy eating and chewingCurrently eats quicklyHistory of eating quicklyCurrent concerns with growth curveHistory of concerns with growth curveCurrent concerns with weight gainHistory of concerns with weight gainCurrent concerns with picky eatingHistory of concerns with picky eatingCurrent concerns with feeding issuesHistory of concerns with feeding issuesCurrent sensory concerns with foodHistory of sensory concerns with food
Please add any specific details or comments regarding your child's feeding history.
Habits:*

Currently uses pacifierHistory of pacifier useCurrently sucks thumb/digitHistory of sucking thumb/digitUses sippy cupHistory of using sippy cupCurrently bites nailsHistory of biting nailsCurrently bites cheekHistory of biting cheekCurrently bites lipHistory of biting lipCurrently sucks or chews on objectsHistory of sucking or chewing on objectsNone of the above
Please add any specific details or comments regarding your child's habits.
Dental history:*

Current TMJ concernsHistory of TMJ concernsCurrently uses night guardHistory of night guard useCurrently uses orthodonticsHistory of orthodontic useHistory of fillingsHistory of crownsHistory of extractionsOrthodontic relapseNone of the above
Please add any specific details or comments regarding your child's dental history.
Sleep issues:*

Currently sleeps in strange positionsHistory of sleeping in strange positionsCurrently kicking/flailing around at nightHistory of kicking and flailing around at nightCurrently wakes easily or oftenHistory of waking easily or oftenCurrently wets the bedHistory of wetting the bedCurrently wakes up tired and not refreshedHistory of waking up tired and not refreshedCurrently grinds teeth while sleepingHistory of grinding teeth while sleepingSleeps with mouth openHistory of sleeping with mouth openCurrently gasps for air or stops breathing (sleep apnea)History of gasping for air or stopped breathing (sleep apnea)Suspected sleep apneaDiagnosed with sleep apnea or UARSCurrently breathes heavyHistory of breathing heavyCurrently breathes loudyHistory of breathing loudlyCurrently snores while sleepingHistory of snoring while sleepingSleep study completedNone of the above
Please add any specific details or comments regarding your child's sleeping.
Speech issues:*

Current frustration with communicationHistory of frustration with communicationCurrently difficult to understand by parentsHistory of difficultly understanding by parentsCurrently difficult to understand by outsidersHistory of difficulty understanding by outsidersCurrent difficulties speaking fastHistory of difficulties speaking fastCurrent difficulties getting words out (groping for words)History of difficulties getting words out (groping for words)Currently stuttersHistory of stutteringCurrently hard to understand in long sentencesHistory of hard to understand in long sentencesCurrently mumbles or speaks softlyHistory of mumbling or speaking softlyCurrently “baby talks”History of "baby talking"Current trouble with saying some soundsHistory of trouble with saying some soundsCurrent speech delayHistory of speech delayDo you understand your child when other less familiar people do not?Previous speech therapyNone of the above
Please add any specific details or comments regarding your child's speech.
Breathing issues:*

Currently breathes with mouth openHistory of breathing with mouth openCurrently has asthma issuesHistory of asthma issuesCurrently has allergiesHistory of allergiesCurrently breathes noisely/audiblyHistory of breathing noisely/audiblyCurrently yawns/sighs frequentlyHistory of yawning/sighing frequentlyCurrently has dry, chapped lipsHistory of dry, chapped lipsCurrently has halitosis (Bad breath)History of halitosis (bad breath)None of the above
Please add any specific details or comments regarding your child's breathing.
Other related issues:

Current neck or shoulder pain/tensionHistory of neck or should pain/tensionCurrent TMJ pain, clicking or poppingHistory of TMJ pain, clicking or poppingCurrently has headaches or migrainesHistory of headaches or migrainesCurrently has strong gag reflexHistory of strong gag reflexCurrently has reflux (medicated or not)History of reflux (medicated or not)Currently hyperactive/inattentiveHistory of hyperactivity/inattentionCurrently constipatedHistory of constipationTonsils or adenoids removed previouslyEar tubes previously
What are your goals and desired outcomes for the evaluation and possible therapy program?*
What is your child's favorite TV show?
What is your child's favorite food?
What is your child's favorite outside activity?
Does your family have a pet? If so, what kind(s)?
Do you (the caregiver) read books or listen to podcasts?
What languages do you (the caregiver) speak?
Tell us a little about your family!
Your name*

First NameLast Name
Relation to patient*
Today's date*

MonthDayYear
Should be Empty:

New Patient Form - Child