Child Patient Information Form

Child Patient Information Form
Patient Name*
Email*
example@example.com
DOB*

MonthDayYear
Date
Sex*

MaleFemale
Pronouns

She/HerHe/HimThey/Them
Social Security #
Have we treated any family members?
Who can we thank for referring you to our office?
I prefer to be seen in your:

Lawrence OfficeTopeka OfficeBaldwin Office
School
Hobbies
Parent 1
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*

MonthDayYear
Date
Social Security #*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Employer*
Years Employed*
Parent 2
Name
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Social Security #
Phone Number

Area CodePhone Number
Email
example@example.com
Employer
Years Employed
Dental Insurance
Do you have dental insurance coverage?*

YesNo
Policy Holder
DOB

MonthDayYear
Date
Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Member ID/ Social Security #
Name of Insurance Company
Employer
Do you have secondary insurance coverage? ( Even if there is no orthodontic benefit, please fill out)

YesNo
Policy Holder
DOB

MonthDayYear
Date
Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Member ID/ Social Security #
Name of Insurance Company
Employer
NOTICE: DO NOT SIGN THIS AGREEMENT BEFORE YOU READ AND AGREE TO THE CONDITIONS ABOVE. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN.
Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important role with the dentistry you receive. Thank you for answering the following questions:
Dentist*
Date of Last Dental Cleaning*

MonthDayYear
Date
Main Concern
Are you under a physician's care now? If yes, Name or Group Name?
Have you ever had a serious head or neck injury? If yes, please explain.
Are you taking any medications, pills, or drugs? If yes, please explain.
Have you ever taken Fosamax, Boniva, or Actonel? If yes, please explain.
Do you use controlled substances? If yes, please explain.
Do you use tobacco?

YesNo
Have you seen an orthodontist?

YesNo
Have you been treated by an orthodontist?

YesNo
Are you currently experiencing pain related to TMJ or other dental issues? If yes, please explain.
(Women) Are you pregnant/trying to get pregnant?

YesNo
Are you allergic to any of the following?

AspirinPenicillinMetal/NickelLatexCodeineAcrylicSulfa DrugsLocal Anesthetics
If yes, please explain.
Do you have, or have you had, any of the following?

AIDS/HPVAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DiseaseConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
Have you ever had any serious illness not listed above? If so, please explain.
Comments
HIPAA RELEASE AND WAIVER

(Guide to Patient Privacy Rules Is in Waiting Room)
Signature For Health History

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Patient/Responsible Party Signature*

Clear
Responsible Party Name*
Date*

MonthDayYear
Date
Should be Empty:

Child Patient Information Form

Parent 1

Parent 2

Dental Insurance

Medical History

HIPAA RELEASE AND WAIVER

Signature For Health History