Child Patient Information Form

Child Patient Information Form
Name*

First NameMiddle NameLast Name
Nickname
Sex*

MaleFemale
Birth Date*

MonthDayYear
Date
Age*
Social Security #
School
Grade
College
Hobbies/Sports
Home Phone*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
E-mail Address*
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is accompanying you today? *
Relation to you?*
Does this person have legal custody of you?*

YesNo
Dentist's Name*
Phone #*
Please enter a valid phone number.
Date Of Last Visit*

MonthDayYear
Date
Physician's Name*
Phone #*
Please enter a valid phone number.
Date Of Last Visit*

MonthDayYear
Date
Other Family Members Seen By Us
How did you hear about us?
Guardian One Information
I am the:*

MotherStep MotherGuardian
Name*
Birthday*

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Address (If Different From Patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address
example@example.com
Employer
Does the patient live with you full time?*

YesNo
Guardian Two Information
I am the:*

FaterStep FatherGuardian
Name*
Birthday*

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Address (If Different From Patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address
example@example.com
Employer
Does the patient live with you full time?*

YesNo
Person Responsible Account
Name*
Birthday*

MonthDayYear
Date
Relation to patient*
Employer
Driver License Number
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Social Security #
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Orthodontic Insurance
Do you have orthodontic insurance?*

YesNo
Group Number (Plan, Local or Policy #)
Insurance Co. Name
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone
Please enter a valid phone number.
Policy Owner's Name
Relation to Patient
Policy Owner's Social Security #
Policy Owner's Date of Birth

MonthDayYear
Date
Policy Owner's Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Have you ever been evaluated or had orthodontic treatment before?*

YesNo
Have you been informed of any missing or extra permanent teeth?*

YesNo
Do you still have your wisdom teeth?*

YesNo
Have you experienced problems with previous dental work?*

YesNo
Have you ever had any pain / tenderness in your jaw joint (TMJ/TMD)?*

YesNo
Has your jaw ever clicked, popped or locked?*

YesNo
Do you brush your teeth daily?*

YesNo
Do you floss your teeth daily?*

YesNo
Do your gums bleed?*

YesNo
Do you play any musical instruments? If so, what?*
Have there been any injuries to your face, mouth, teeth or chin?*

YesNo
Do you currently feel healthy?*

YesNo
Do you need to be premedicated before dental work?*

YesNo
Are you taking fluoride supplements?*

YesNo
Have adenoids or tonsils been removed?*

YesNo
Are Immunizations current?*

YesNo
Boys: Has puberty begun?

YesNo
Boys: Has your voice changed?

YesNo
Girls: Has puberty begun?

YesNo
Girls: Do you take birth control pills?

YesNo
Girls: Are you pregnant?

YesNo
Please list all medications that you are currently taking:*
Are you Allergic to any of the following?*

AspirinAny Metal (e.g.Nickel)PlasticCodeineDental AnestheticsErythromycinLatexPenicillinTetracyclineSulfa drugsOtherNone
Please list any other Allergies that you have:*
Do you now have or have you had any of the following habits?*

Tongue ThrustClenching / Grinding TeethLip Sucking / BitingSpeech ProblemsMouth BreatherNail BitingOtherNone
Please list any other Habits that you have:*
Do you now have or have you had any of the following?*

AllergiesAbnormal/Bleeding DisordersAny Hospital StaysAsthmaCancerCanker SoresCardiovascular diseaseChicken PoxCold Sores / Fever BlistersConvulsions / EpilepsyDamaged / artificial heart valvesDiabetesHandicaps / DisabilitiesHearing ImpairmentHeart MurmurHemophiliaHepatitis/Liver ProblemsHigh Blood PressureHivesHIV+ / AIDSKidney ProblemsMeaslesMononucleosisPsychological CounselingRheumatic / Scarlet FeverSkin RashTuberculosis (TB)Tumors/growthsUlcersNone
Signature
Our office is committed to meeting or exceeding the standards of infection control
mandated by OSHA, the CDC and the ADA.

We reserve the right to verify the credit status prior to extending credit for treatment.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Child Patient Information Form

Guardian One Information

Guardian Two Information

Person Responsible Account

Orthodontic Insurance

Medical History

Signature