Child Patient Information
Patient Name
*
First Name
Last Name
Nickname/Preferred Name
Gender
Male
Female
Prefer not to state
They/Them
Social Security Number
BirthDate
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Phone Type
*
Home
Cell
If cell, please list service provider
Email
*
example@example.com
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Person Responsible For Account
Person #1
Full Name
Please list who has legal custody of the child.
*
Do you have legal custody of the child?
Yes
No
Marital Status
Single
Married
Divorced
Widowed
Significant Other
Social Security Number
Relation to Child
Birthdate
-
Month
-
Day
Year
Date
Address (if different than child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Phone Type
Home
Cell
If cell, please list provider
Secondary Phone
Phone Type
Home
Cell
If cell, please list provider
Employer's Name
Occupation
Person Responsible For Account
Person #2
Full Name
Please list who has legal custody of the child.
Do you have legal custody of the child?
Yes
No
Marital Status
Single
Married
Divorced
Widowed
Significant Other
Relation to Child
Social Security Number
Birthdate
-
Month
-
Day
Year
Date
Address (if different than child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Phone Type
Home
Cell
Secondary Phone
Please enter a valid phone number.
Phone Type
Home
Cell
Employer's Name
Occupation
Please list who will be financially responsible for the account
Emergency Contact Information
Emergency Contact Name (other than parent)
Phone Number
Relation to Child
Primary Dental Insurance Information
Primary Insurance Company
Phone Number
Subscriber Name
Policy Holder's SSN
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Secondary Dental Insurance Information
Secondary Insurance Company
Phone Number
Subscriber Name
Policy Holder's SSN
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Dental History
General Dentist
*
Date of Last Visit
-
Month
-
Day
Year
Date
How did you hear about our practice?
*
Ad
Internet
Family/Friend
Dentist
Other
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to correct?
*
Has your child visited an orthodontist before?
Yes
No
If yes, when
-
Month
-
Day
Year
Date
Reason for visit
Have we treated any other family members?
Yes
No
Has your child's tonsils or adenoids been removed?
Yes
No
Do you have any missing or extra permanent teeth?
Yes
No
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Teeth
Mouth
Chin
TMJ/TMD/Jaw
Does your child have speech problems?
Yes
No
If so, please explain:
Does your child currently or has your child ever had any of the following habits (check all that apply):
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem
Medical History
Is your child currently being treated by a physician?
*
Yes
No
Name of Primary Care Physician:
Reason for Last Visit:
Does your child have any allergies/sensitivities to medications or latex?
*
Yes
No
If yes, please list:
Is your child currently taking any prescription or over-the-counter medications?
*
Yes
No
If yes, please list with the dosage:
Has your child had any serious illnesses or operations? If yes, describe:
*
Check if your child has or has ever had any of the following
*
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Headaches
Heart Murmur
Heart Problems
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Shortness of Breath
Stroke
Thyroid Problems
Tobacco Habit
Tonsilitis
Tuberculosis
Ulcer
None
Authorization
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
Submitted by
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
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