Child New Patient Form

Child New Patient Form
Patient Name*
Sex*

MaleFemale
Identifies as*

MaleFemaleNon-binaryPrefer not to respond
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nickname
Birthdate*

MonthDayYear
Date
Social Security #
School
Sports/Hobbies
Parent/Guardian Name*
Whom may we thank for referring you to our office?*
Responsible Party Information
Name*
Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (If less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell/Other Phone*
Please enter a valid phone number.
Email Address*
example@example.com
Social Security #
Birthdate

MonthDayYear
Date
Relationship to patient
Employer
Occupation
No. of years employed
Spouse's name
Relationship to patient
Birthdate

MonthDayYear
Date
Social Security #
Employer
Occupation
No. of years employed
Work Phone
Please enter a valid phone number.
Dental Insurance Information

I understand that, where appropriate, credit bureau reports may be obtained.
Do you have dental insurance?*

YesNo
Insured's name*
Insured's DOB*

MonthDayYear
Date
Insured's SSN*
Subscriber Employer*
Insurance Company*
Group No.*
ID Number*
Insurance Co. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Phone Number*
Please enter a valid phone number.
Insurance Card

Please upload photos of front & back of insurance card
Cancelof
Do you have dual coverage?*

YesNo
Insured's name*
Insured's DOB*

MonthDayYear
Date
Insured's SSN*
Subscriber Employer*
Insurance Company*
Group No.*
ID Number*
Insurance Co. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Phone Number*
Please enter a valid phone number.
Insurance Card

Please upload photos of front & back of insurance card
Cancelof
Emergency Information
Name of nearest relative not living with you*
Complete Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Medical History
Physician
Date of last visit

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Is the patient taking any medication? If yes, please provide details.*
Is the patient allergic to any medication? If yes, please provide details.*
Has the patient had any operations? If yes, please provide details.*
Ever been involved in a serious accident? If yes, please provide details.*
Have seen a physician in the last 12 months? If yes, please provide details.*
Female patients only: Has menstruation started?*

YesNoN/A
Female patients only: Is the patient pregnant?*

YesNoN/A
Check yes to any of the medical conditions below that the patient has had or currently has.
Check any of the medical conditions below that the patient has had or currently has.*

Abnormal bleeding/HemophiliaAnemiaArthritisAsthma or HayfeverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver ProblemsHerpesHigh Blood PressureHIV/AidsKidney problemsNervous DisordersPneumoniaProlonged BleedingRadiation/ChemotherapyRheumatic FeverTuberculosisTumor or CancerSleep ApneaPremature BirthNone
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist*
Date of last visit*

MonthDayYear
Date
What concerns you most about your teeth?*
Is the patient presently in any dental pain? If yes, please explain.*
Ever experienced any unfavorable reaction to dentistry? If yes, please explain.*
Has the patient ever lost or chipped any teeth? If yes, please explain.*
Have there been any injuries to face, mouth, or teeth? If yes, please explain.*
Is any part of your mouth sensitive to temperature? Where?*
Is any part of your mouth sensitive to pressure? Where?*
Do gums bleed when brushing? If yes, please explain.*
Any type of thumb or tongue habit? If yes, please explain.*
Is the patient a mouth breather? If yes, please explain.*
Has the patient ever seen an orthodontist? If yes, who and when?*
What is the patient's attitude toward receiving orthodontic treatment?*
Has anyone in the family received orthodontic treatment? If yes, how did they feel about the result?*
Do teeth or jaws ever feel uncomfortable first thing in the morning? If yes, please explain.*
Aware of clenching or grinding teeth during the day? If yes, please explain.*
Experience "tension" headaches? If yes, please explain.*
Has the patient ever experienced chronic ringing in the ears? If yes, please explain.*
Does the patient need extra help with instructions? If yes, please explain.*
Is the patient sensitive or self-conscious about his/her teeth? If yes, please explain.*
Height of Mom?
Height of Dad?
Are you aware that some appointments will be during school hours?*

YesNo
Preferred Contact
The HIPAA Privacy Rule gives individuals the right to direct how and where their healthcare provider communicates with them, such as sending correspondence to the individual’s office instead of their individual’s home.

We invite you to share with us your preferred place and manner of communication. You may update or change this information at any time; please do so in writing.

I prefer to be contacted in the following manner (check all that apply)
Home Telephone

OK to leave message with detailed informationLeave message with call-back number by
Cell Phone

OK to send a text message with detailed informationOK to leave message with detailed informationLeave message with call-back number by
Work Telephone

OK to leave message with detailed informationLeave message with call-back number by
Written Communication

OK to mail to my home addressOK to mail to my work/office address
Other
We respect your right to indicate who you prefer that we involve in your treatment or payment decisions and/or who we share your information with, including information about your general medical condition and diagnosis (such as treatment and payment options), access to medical records (PHI), prescription pick-up and scheduling appointments. Please note, however, that we may share your information as set forth in our Notice of Privacy Practices to other persons as needed for your care or treatment or the payment of services we have provided. Please update the information promptly if your preferences change.

Please indicate the person(s) your prefer we share your information with below:

	Full Name	Phone	Relationship
Contact 1
Contact 2
Contact 3

Informed Consent
Privacy Policy

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.
Benefits
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Hamer & Glassick Orthodontics to perform a complete orthodontic evaluation.
Patient Signature*

(To be signed by patient’s parent or legal guardian if patient is a minor or otherwise not competent) Clear
Date*

MonthDayYear
Date
Should be Empty:

Child New Patient Form

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Dental History

Preferred Contact

Informed Consent

Privacy Policy

Benefits