Child New Patient Form

Child New Patient Form
Patient Name:*

First NameLast Name
Gender:*

MaleFemaleOther
Birth Date:*

MonthDayYear
Date
Age:
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
Please enter a valid phone number.
Phone Type:*

HomeCell
OK to leave message?*

YesNo
Email:*
example@example.com
School:
Grade:
Sports or extracurricular activities:
Siblings (names and ages):
Parent / Guardian Information
Parent 1
Name*

First NameLast Name
Marital Status:*

SingleMarriedDivorcedWidowedSignificantOther
Relation to Child:*

MotherFatherGuardianStep-ParentOther
Birth Date:

MonthDayYear
Date
Address (if different than child's):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
Please enter a valid phone number.
Phone Type:*

HomeCell
Secondary Phone Number:
Please enter a valid phone number.
Phone Type:

HomeCell
Parent 2
Name*

First NameLast Name
Marital Status:*

SingleMarriedDivorcedWidowedSignificantOther
Relation to Child:*

MotherFatherGuardianStep-ParentOther
Birth Date:

MonthDayYear
Date
Address (if different than child's):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
Please enter a valid phone number.
Phone Type:*

HomeCell
Secondary Phone Number:
Please enter a valid phone number.
Phone Type:

HomeCell
Emergency Contact Information
Emergency Contact Name (other than parent):*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Relation to Child:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) you allow us to release appointment or medically-related information regarding your child to:*
Relation(s) to Child:*
Insurance Information
Do you have primary insurance coverage?*

YesNo
Primary Insurance Company:
Phone Number:
Please enter a valid phone number.
Group Number:
Policy Number:
Member ID Number:
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:

MonthDayYear
Date
Employer:
Work Phone Number:
Please enter a valid phone number.
Do you have secondary insurance coverage?

YesNo
Secondary Insurance Company:
Phone Number:
Please enter a valid phone number.
Group Number:
Policy Number:
Member ID Number:
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:

MonthDayYear
Date
Employer:
Work Phone Number:
Please enter a valid phone number.
Dental History
General Dentist:*
Last Visit:*
How did you hear about our practice?

AdInternetFamily/FriendDentistOther
What are the main concerns you would like orthodontics to correct?*
Has your child visited an orthodontist before?

YesNo
If yes, when? Reason?
Have we treated any other family members?

YesNo
If yes, names:
Have your child's tonsils or adenoids been removed?

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

YesNo
Does your child have any missing or extra permanent teeth?

YesNo
Has your child ever had an injury to (select all that apply):

TeethMouthChinN/A
Does your child have speech problems?

YesNo
If yes, explan:
Does your child currently or has your child ever had any of the following habits (check all that apply):

Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating ProblemN/A
Medical History
Is your child currently being treated by a physician?*

YesNo
Reason:
Physician:
Last Visit:

MonthDayYear
Date
Phone:
Please enter a valid phone number.
Do you have any allergies/sensitivities to medications or latex?*

YesNo
If yes, please list:
Is your child currently taking any prescription or over-the-counter medications?*

YesNo
If yes, please list with the dosage:
Has puberty and/or menstruation begun?*

YesNoN/A
Has your child had any serious illnesses or operations?*

YesNo
If yes, describe:
Has your child ever had a blood transfusion?*

YesNo
If yes, give approximate dates:
Check if your child has or has ever had any of the following:*

AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsilitisTuberculosisUlcerVenereal Disease (STD)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.

I understand that where appropriate, credit bureau reports may be obtained.
Submitted by:*
Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Child New Patient Form

Parent / Guardian Information

Emergency Contact Information

Insurance Information

Dental History

Medical History

Authorization