Child Patient Information Form

Welcome to Shiney Smiles Orthodontics and congratulations! By making an appointment, you have taken the first step in revealing a beautiful smile. We consider it a great honor that you have chosen our team to provide you with exceptional orthodontic care.

Our goal is to provide each of our patients with the highest quality care. We endeavor to treat our patients, as we would like to be treated: gently, efficiently and enthusiastically. We strive to help our patients understand their orthodontic treatment and how we can help them maintain a natural, healthy and attractive smile for a lifetime.

Generally, your first visit will consist of a consultation. At this appointment we will determine not only if you are a good candidate for orthodontics but also if it is the correct time to begin treatment. If orthodontics is indicated we will take appropriate records including a thorough evaluation, radiographs, dental scans and photographs. Subsequently, we will be able to discuss and answer any questions you may have concerning the proposed treatment, length of treatment and financial arrangements.

We invite you to visit our website at: www.ShineySmilesOrtho.com. Here you can find information about our office and what you can expect from orthodontic treatment. Additionally, you can find information about the different types of appliances available, including visible and invisible options. You can also see what we're up to in the office by following our Instagram and Facebook @ShineySmilesOrtho!

Time has been reserved exclusively for you on the date you scheduled for your consult. Advance notice is appreciated should you need to reschedule your appointment. Please have any available dental insurance information with you at this time. | consider your first appointment in our orthodontic office a valuable opportunity to meet you and your child, for you to meet our team, and for you to become confident in the quality of our care. Please feel comfortable in contacting us at 516-921-6010, should you have any questions or concerns regarding this appointment. | look forward to meeting you at your scheduled time.

Welcome!
Michael Sheinis D.D.S. and the Shiney Smile Team

Patient’s Name*

Nickname

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Cell Phone Provider

SSN

DOB

Date

Age

Sex

School

Grade

Hobbies

General/Pediatric Dentist

City

Last Visit

Whom may we thank for referring you to our office?

Siblings (Names and Ages)

Parent/Guardian 1 Name

Relation

Address (If different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long?

Email Address

example@example.com

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Cell Phone Provider

SSN

DOB

Date

Employer

Occupation

How long?

Parent/Guardian 2 Name

Relation

Address (If different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long?

Email Address

example@example.com

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Cell Phone Provider

SSN

DOB

Date

Employer

Occupation

How long?

Orthodontic Coverage?*

YesNo

Insured’s Name

Relation

Employer

DOB

Date

SSN

Insurance Company

Group No.

Insurance IDN

Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Company Phone

Please enter a valid phone number.

Do you have dual coverage?

YesNo

Insured’s Name

Relation

Employer

DOB

Date

SSN

Insurance Company

Group No.

Insurance IDN

Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Company Phone

Please enter a valid phone number.

Contact Person*

Relation*

Phone Number*

Please enter a valid phone number.

Physician’s Name

Last Visit

Date

Phone Number

Please enter a valid phone number.

Current physical condition

GoodFairPoor

Are you currently under the care of a physician?

YesNo

Have you ever been under the care of a physician for a major illness? If so, explain:

Please answer all questions by checking ‘Yes’ or ‘No”.

Good Health*

YesNo

Recent illness*

YesNo

Recent cold, cough*

YesNo

Heart or chest pain*

YesNo

Heart murmur*

YesNo

High blood pressure*

YesNo

Rheumatic fever*

YesNo

Kidney disease*

YesNo

Lung disease*

YesNo

Diabetes*

YesNo

Hepatitis*

YesNo

Herpes (cold sores)*

YesNo

AIDS or HIV positive*

YesNo

Endocrine disorder*

YesNo

Growth disorder*

YesNo

Tonsils/Adenoids removed*

YesNo

Bleeding disorder*

YesNo

Prolonged bleeding*

YesNo

Leukemia*

YesNo

Sickle cell anemia*

YesNo

Anemia*

YesNo

Joint replacement*

YesNo

Arthritis*

YesNo

Asthma*

YesNo

Sinus problems*

YesNo

Hay fever, seasonal allergies*

YesNo

Nasal obstruction*

YesNo

Severe headaches*

YesNo

Bone disorder*

YesNo

Epilepsy*

YesNo

Canker Sores*

YesNo

Antibiotics required forDental appointments*

YesNo

List any drugs (prescription and over the counter) that you are currently taking and please give reason:

List any allergies or sensitivities; Including drug, latex metal or other:

Are you taking any medication for osteoporosis? If so, what and for how long?

Are you now, or could you be pregnant? If yes, how many weeks?

Has patient reached puberty?

YesNo

Girl – Started Menstruation

YesNo

Boy – Voice Changed/Facial hair

YesNo

What are the main concerns you would like orthodontics to accomplish?

Current Dental Health

GoodFairPoor

Do you like your smile?

YesNo

Have you ever been treated with orthodontics before? If yes, please explain:

Family history of orthodontic treatment

YesNo

Has the patient ever sucked a thumb or finger?

YesNo

Has your child ever experienced pain / discomfort in your jaw joint (TMJ/TMD)?

YesNo

Does your child have a tongue thrust?

YesNo

Any history of speech problems?

YesNo

Has your child ever had injuries to your face, mouth, teeth or chin?

YesNo

Does your child generally breath through their mouth while awake?

YesNo

Does your child generally breath through their mouth while asleep?

YesNo

Does your child have any missing or extra permanent teeth?

YesNo

Signature*

Date*

Date

Child Patient Information Form

Responsible Party Information

Orthodontic Insurance Information

Emergency Information

Medical History

Dental History

HIPAA

Signature