Welcome to the Orthodontist

Yao Orthodontics

New Patient Form
Child's Name *

First Last
Child's Birthdate

Month Day Year
Age of Patient

Child Adult
Email *
School:
Grade
Special Interests, Hobbies/Sports:
Siblings Names and Date of Birth
General Dentist:
Last Visit Date:
Whom may we Thank for referring you?
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone #

Area Code Phone Number
Cell Phone #

Area Code Phone Number
Information Must Be Filled Out Completely
Custodial Parent Information

Patient Information
Parent:

Mother Father Step Parent Guardian
Name

First Name Last Name
Child's Birthdate

Month Day Year
Work Phone #

Area Code Phone Number
Cell #

Area Code Phone Number
Home Phone #

Area Code Phone Number
Employer
Social Security #
Additional Parent Information
Name

First Name Last Name
Birthdate
Cell #

Area Code Phone Number
Home Phone #

Area Code Phone Number
Work Phone #

Area Code Phone Number
Employer
Social Security #
Drivers License Number
Primary Orthodontic Insurance
Policy Holder's Name
Policy Owner's Birthdate

Month Day Year
Date
Social Security Number or ID Number
Employer Name
Insurance Company Name
Insurance Company Phone #

Area Code Phone Number
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Relationship to Patient
Secondary Insurance
Policy Owner's Name
Policy's Owner's Birthdate

Month Day Year
Date
Social Security #
Employer Name
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company Phone #

Area Code Phone Number
Group # (Plan, Local or Policy #)
Relationship to Patient
What are the main concerns you would like orthodontics to address?
Parent
Your Concerns
Child
Dentist
Has your child ever been evaluated or had orthodontic treatment before?

Yes No
Have there been any injuries to the face, teeth, jaw, mouth, or chin? Please explain:
Have adenoids or tonsils been removed? *

Yes No
Has your child been informed of any missing or extra permanent teeth?

Yes No
Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)? *

Yes No
Does your child brush his/her teeth daily? *

Yes No
Does your child floss his/her teeth daily?

Yes No
Child's Physician
Phone Number

Area Code Phone Number
Date of Last Visit

Month Day Year
Date
Is your child currently under the care of a physician?

Yes No
Are you currently under the care of a physician?

Yes No
Please describe your child's physical health

Good Fair Poor
Please describe your physical health

Good Fair Poor
Please list all medications that your child is currently taking and for what conditions:
Please list all medications that you are currently taking and for what conditions:
Please list any medications that your child is currently allergic to:
Please list any medications that you are currently allergic to:

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

	Yes	No
Abnormal Bleeding
Allergies to any drugs
Allergy to latex/metals
Allergy to plastic
Any Operations
Asthma
Cancer
Congenital Heart Defect
Diabetes
Epilepsy/Convulsions
Handicaps/Disabilites
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
Kidney / Liver Problems
Rheumatic Fever
Tuberculosis (TB)

Does the patient have any of the following habits?

	Yes	No
Clenching/Griding Teeth
Nurse Bottle Habits
Lip Sucking/Biting
Thumb / Finger Sucking
Mouth Breather
Nail Biting
Speech Problems
Tongue Thrust

If you have/had any other medical issues not listed, please describe.
Please list an emergency contact not living with you
Name

First Name Last Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agree to Terms

I understand that the information I have given today is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I also authorize Yao Orthodontics to perform the necessary orthodontic services my child may need. I further authorize that photos taken during treatment may be used for professional consultations and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.
I agree to the above terms and conditions *

Yes
Should be Empty:

Yao Orthodontics

Custodial Parent Information

Additional Parent Information

Primary Orthodontic Insurance

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