Child Patient Form

Child Patient Form
Child's Name (First & Last):*
Prefers To Be Called:
Birthdate:*

MonthDayYear
Date
Age:
Gender:*

MaleFemaleNon-BinaryPrefer Not To Disclose
School:*
Grade:*
Hobbies/Sports:
Child's Home Phone:*

Area CodePhone Number
Child's Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is accompanying your child today?
Name:*
Relation:*
Do you have legal custody of this child?

YesNo
Whom may we Thank for referring you?*
List brothers / sisters with age:
General Dentist:*
Last Visit Date:
Parent’s Marital Status:*

SingleMarriedPartneredWidowedDivorcedSeparated
Parent #1 Information
Name:*
Birthdate:*

MonthDayYear
Date
Email Address:*
example@example.com
Cell Phone:*

Area CodePhone Number
Home Phone:

Area CodePhone Number
Employer:*
Work Phone:

Area CodePhone Number
Parent #2 Information
Name:
Birthdate:

MonthDayYear
Date
Email Address:
example@example.com
Cell Phone:

Area CodePhone Number
Home Phone:

Area CodePhone Number
Employer:
Work Phone:

Area CodePhone Number
Person Responsible For Account
Name:*
Relation:*

MomDadOther
Billing Address (If different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (if different):

Area CodePhone Number
Who is responsible for making appointments?*
Preferred contact number:*

HomeCellWork
Primary Dental/Orthodontic Insurance
Do you have dental/orthodontic coverage?*

YesNo
Dental Insurance Co. Name:
Dental Insurance Co. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Co. Phone Number:

Area CodePhone Number
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:

MonthDayYear
Date
Insured's ID #:
Insured's Employer:
Secondary Dental/Orthodontic Insurance
Do you have dental/orthodontic coverage?

YesNo
Dental Insurance Co. Name:
Dental Insurance Co. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Co. Phone Number:

Area CodePhone Number
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:

MonthDayYear
Date
Insured's ID #:
Insured's Employer:
Dental History
What are the main goals that you would like orthodontics to accomplish?
Has your child ever taken Phen-Fen? (Also known as Redux or Pondimin) if yes, when?*
Has your child ever had or been evaluated for or had orthodontic treatment before?*

YesNo
Have there been any injuries to the Face, mouth, teeth or chin?*

YesNo
List any musical instruments played:*
Have the adenoids or tonsils been removed?*

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

YesNo
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?*

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

YesNo
Floss his / her teeth daily?*

YesNo
Child’s Physician:*
Phone Number:

Area CodePhone Number
Date Of Last Visit:

MonthDayYear
Date
Please describe your child’s physical health:*

GoodFairPoor
Please list all of the drugs that your child is currently taking:*
Please list all of the drugs / things that your child is allergic to:*
Allergic to latex?*

YesNo
Allergic to metals/nickel?*

YesNo
Allergic to plastics?*

YesNo
Medical History
Has your child ever had any of the following medical problems?*

Abnormal BleedingADD / ADHDAllergies to Any DrugsAllergic to Latex / MetalsAllergies to PlasticAny Hospital StaysAny OperationsArtificial Bones/Joints/ValvesAsthmaCancerCongenital Heart DefectConvulsions / EpilepsyDiabetesHandicaps / DisabilitiesHearing ImpairmentHeart MurmurHemophiliaHepatitisHIV+ / AIDSKidney / Liver ProblemsLupusRheumatic / Scarlet FeverTuberculosis (TB)None
Please discuss any medical problems that your child has had:
Has your child ever experienced any of the following?*

Clenching / Grinding TeethLip Sucking / BitingMouth BreatherNail BiterNursing / Bottle HabitsSpeech ProblemsThumb / Finger SuckingTongue ThrustNone
Thank you for filling out this form completely.
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 confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

This office reserves the right to verify the credit status of potential patients
and / or parents of patients prior to extending credit for treatment fees and
may, at the discretion of the office, use the services of one or more credit
reporting services.

I authorize the dental staff to perform any necessary dental services my child may need.
Signature:*

Clear
Date Submitted:*

MonthDayYear
Date
Should be Empty:

Child Patient Form

Who is accompanying your child today?

Parent #1 Information

Parent #2 Information

Person Responsible For Account

Primary Dental/Orthodontic Insurance

Secondary Dental/Orthodontic Insurance

Dental History

Medical History

Thank you for filling out this form completely.