Child Patient Form

Child's Name (First & Last):*

Prefers To Be Called:

Birthdate:*

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

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:*

Name:*

Birthdate:*

Date

Email Address:*

example@example.com

Cell Phone:*

Area CodePhone Number

Home Phone:

Area CodePhone Number

Employer:*

Work Phone:

Area CodePhone Number

Name:

Birthdate:

Date

Email Address:

example@example.com

Cell Phone:

Area CodePhone Number

Home Phone:

Area CodePhone Number

Employer:

Work Phone:

Area CodePhone Number

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

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:

Date

Insured's ID #:

Insured's Employer:

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:

Date

Insured's ID #:

Insured's Employer:

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:

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

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

Please discuss any medical problems that your child has had:

Has your child ever experienced any of the following?*

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:*

Date Submitted:*

Date

Patient Name*

Email Address

example@example.com

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
To third-party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
Internally, to all staff members who have any role in your treatment;
To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
To your family and close friends involved in your treatment; and/or
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

Request restrictions on the use and disclosure of your protected health information;
Request confidential communication of your protected health information;
Inspect and obtain copies of your protected health information through asking us;
Amend or modify your protected health information in certain circumstances;
Receive an accounting of certain disclosures made by us of your protected health information; and,
You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

We have the following duties under the privacy rules:

By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
To abide by the terms of our Privacy Notice that is currently in effect; and,
To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:

Amend your protected health information if, for example, it is accurate and complete; or,
Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.

I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

Signature*

Date Submitted*

Date

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.

Privacy Practice