Child Patient Form

Patient Name*

First NameLast Name

Gender*

MaleFemale

Social Security Number*

Birth Date*

Date

Age*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Phone Type*

HomeCell

Ok to leave message?*

YesNo

Email*

example@example.com

School

Grade*

List any sports or extracurricular activities

Siblings (names and ages)

Full Name

Marital Status

Social Security Number*

Relation to Child

MotherFatherStep-ParentOther

Birthdate

Date

Driver's License Number

Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone

Phone Type

HomeCell

Secondary Phone

Phone Type

HomeCell

Employer's Name*

Occupation*

How long at this current job?*

Full Name

Marital Status

Relation to Child

MotherFatherStep-ParentOther

Social Security Number

Birthdate

Date

Driver's License Number

Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

At your home address, do you:

RentOwn

How long have you lived at your current address?*

Previous Address (if less than 3 years at current address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone

Please enter a valid phone number.

Phone Type

HomeCell

Secondary Phone

Please enter a valid phone number.

Phone Type

HomeCell

Employer's Name

Occupation

How long at this current job?

Emergency Contact Name (other than parent)

Phone Number

Relation to Child

Primary Insurance Company

Phone Number

Subscriber Name

Policy Holder's SSN

Policy Holder's Date of Birth

Date

Picture Upload of Front & Back of Insurance Card

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General Dentist

Date of Last Visit

Date

How did you hear about our practice?

Name of person referring (if applicable)

What are the main concerns you would like orthodontics to correct?

Has your child visited an orthodontist before?

YesNo

If yes, when

Date

Reason for visit

Have we treated any other family members?

YesNo

Has your child's tonsils or adenoids been removed?

YesNo

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo

Do you have any missing or extra permanent teeth?

YesNo

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

TeethMouthChin

Does your child have speech problems?

YesNo

If so, please explain:

Does your child currently or has your child ever had any of the following habits (check all that apply):

Is your child currently being treated by a physician?

YesNo

Name of Primary Care Physician:

Reason for Last Visit:

Does your child have any allergies/sensitivities to medications or latex?

YesNo

If yes, please list:

Is your child currently taking any prescription or over-the-counter medications?

YesNo

If yes, please list with the dosage:

Have you had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?

YesNo

If yes, give approximate dates

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

Date

MonthDayYear

Submitted by

Date

Signature

Clear

Child Patient Information

Parent/Guardian

Parent/Guardian

Emergency Contact Information

Primary Dental Insurance Information

Dental History

Medical History

Authorization