Welcome to the Orthodontist

Child New Patient Form
We would like to welcome you and your child to our office. Our goal is to make everyone's visit pleasant, stress-free and educational. We pride ourselves in creating beautiful smiles that lasts a lifetime. We look forward to seeing you in the office.
Child's Name*

FirstLast
Child's Birthdate

MonthDayYear
Date
Name your child prefers to be called?
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

CityState / Province

Postal / Zip CodeCountry
Home Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Information Must Be Filled Out Completely

x
Custodial Parent Information

Patient Information
Relationship*
Responsible Party?*
Marital Status?*
Name of Parent/Guardian*

First NameLast Name
Parent/Guardian Birthdate*

MonthDayYear
Date
Work Phone #

Area CodePhone Number
Cell #*

Area CodePhone Number
Home Phone #

Area CodePhone Number
Employer*
Social Security #
Driver's License #
Additional Parent Information
Name

First NameLast Name
Parent/Guardian Birthdate:
Cell #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Address (If different)
Employer
Social Security #
Drivers License Number
Primary Orthodontic Insurance
Policy Holder's Name

First NameLast Name
Policy Owner's Birthdate

MonthDayYear
Date
Social Security Number or ID Number
Employer Name
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Date
Social Security #
Employer Name
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #

Area CodePhone Number
Group # (Plan, Local or Policy #)
Member ID
Relationship to Patient
What are the main concerns you or your child's dentist would like orthodontics to address?
Explain
Has your child ever been evaluated or had orthodontic treatment before?

YesNo
Have there been any injuries to the face, teeth, jaw, mouth, or chin? Please explain:
Have adenoids or tonsils been removed?*

YesNo
Has your child been informed of any missing or extra permanent teeth?

YesNo
If yes, which ones?
Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)?*

YesNo
Does your child brush his/her teeth daily?*

YesNo
Does your child floss his/her teeth daily?

YesNo

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

Medical History
Child's Physician
Phone Number

Area CodePhone Number
Date of Last Visit

MonthDayYear
Date
Is your child currently under the care of a physician?

YesNo
Please describe your child's physical health

ExcellentGoodFairPoor
Please list all medications that your child is currently taking and for what conditions:
Please list any medications that your child is currently allergic to:
If your child is a girl, has menstruation begun?

YesNo
If Yes, how long ago?

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)
Any Hospital Stays
HIV +/AIDS

Please list an emergency contact not living with you
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agree to Terms

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials 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*

YesNo
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**
I ________________________ , have received a copy of this office's Notice of Privacy Practices.
MyselfChild(ren)
Name of child(ren)
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Child New Patient Form

Information Must Be Filled Out Completely

Custodial Parent Information

Additional Parent Information

Primary Orthodontic Insurance

Secondary Insurance

What are the main concerns you or your child's dentist would like orthodontics to address?

Medical History

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES