Falls Orthodontics Registration and HHF

Patient Name *

First Name Middle Name Last Name

Nickname/ Preferred Name *

Gender *

Female Male

Patient Birthdate *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

What school do you attend?

Please list any siblings and their ages:

Please list any family members treated in our office:

What are your interests? Sports? Hobbies?

How did you hear about us? *

What are your orthodontic concerns? *

Were you thinking of braces, clear aligners like Invisalign, or unsure? *

Braces Invisalign Expander Unsure

Is this a second opinion? *

Yes, I have had another consultation Yes, but I have not yet seen the other orthodontist No

Primary Responsible Party Name *

First Name Last Name Relationship to Patient

Primary Responsible Party Email *

example@example.com

Primary Responsible Party Primary Phone *

Please enter a valid phone number.

Would you like text message appointment reminders? *

Yes No

Primary Responsible Party Address (if different than above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Second Responsible Party Name

First Name Last Name Relationship to Patient

Second Responsible Party Address (if different than above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Second Responsible Party Email

example@example.com

Second Responsible Party Primary Phone

Please enter a valid phone number.

Please list below any other individuals we are allowed to share patient information with (otherwise we only share information with the patient directly or both parents). If there are no other parties - please write NONE: *

Is there dental insurance that covers orthodontic treatment? *

Yes (please bring primary card to the exam appointment) Yes and more than one (please bring secondary card to the exam appointment) Yes and it is ForwardCare or Medical Assistance No Other

Primary Dental Insurance Company

Name of Guardian that Carries the this Insurance

Date of Birth of Primary Insurance Carrier

Date

Subscriber ID # (or social security number if that is not available)

Employer Name of Primary Insurance Carrier

Secondary Dental Insurance Company

Date of Birth of Secondary Insurance Carrier

Date

Secondary Subscriber ID # (or social security number if that is not available)

Dentist Name *

First Name Last Name

Dental Office City *

Last Visit *

Date

Last Cleaning

Date

Were there any cavities found or dental work needed? *

Yes, and I have it scheduled Yes, but not yet scheduled No

Dental Questionnaire *

	Yes	No
Has the patient had any orthodontic treatment?
Does the patient have any missing teeth?
Does the patient clench or grind their teeth?
Are there any jaw joint issues?
Is there any history of injury to the mouth, face, teeth or chin?
Does the patient chew on pens, fingernails, etc?
Is there a thumb or finger sucking habit?
Is the patient in any contact sports?

Physician Name

Approximate Date of Last Well Visit

Medical Questionnaire *

	Yes	No
Asthma that is medication dependent?
Asthma that is allergy/exercise induced?
AIDS/HIV?
Allergic reactions? (please describe below)
Arthritis?
Autism?
Antibiotics required for dental work?
ADD/ADHD?
Bleeding disorder?
Cancer (current or history of)? (please describe below)
Congenital heart defect?
Convulsions/epilepsy?
Cleft lip/palate?
Diabetes?
Disability? (please describe below)
Fever blisters or cold sores?
Hearing impairment?
Heart murmur?
Hospitalizations? (please describe below)
Headaches(severe)/migraines?
Hepatitis/jaundice/liver disease?
Joint/bone disorders/implants?
Kidney disease?
Sinus problems?
Speech problems?
Tuberculosis?
Venereal disease
Psychiatric or psychological care?
Currently taking any medications? (please describe below)
Allergy to milk?
Have tonsils or adenoids been removed?

If you answered yes to any questions above, please provide details below:

Do you have any other disease/condition not listed above or any other healthcare providers we should be aware of?

Please answer the below screening questions based on how your child acts in general during the past month.

While sleeping does your child: *

	Yes	No	Don't Know
Snore more than half the time?
Always snore?
Snore loudly?
Have "heavy" or loud breathing?
Have trouble breathing or struggle to breathe?
Have you ever seeing your child STOP BREATHING during the night?

General questions: *

	Yes	No	Don't Know
Does your child breathe through their mouth during the day?
Do they have a dry mouth on waking in the morning?
Do they occasionally wet the bed?
Do they wake up feeling unrefreshed in the morning?
Do they have a problem with sleepiness during the day?
Has a teacher or other supervisor ever commented that your child appears sleepy during the day?
Is it hard to wake your child in the morning?
Does your child wake up with headaches in the morning?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?

Behavioral questions - Does your child OFTEN: *

	Yes	No	Don't Know
Not seem to listen when spoken to directly?
Have difficulty organizing tasks and activities?
Easily become distracted by extraneous stimuli?
Fidget with hands or feet or squirms in their seat?
Act as if "driven by a motor" or is "on the go"?
Interrupt or intrude on others (ex. butts into conversations or games)

I give permission and authorize Falls Orthodontics doctors and staff to take diagnostic records for the purpose of planning orthodontic treatment. I allow the use of orthodontic records for professional consultations, research, education, or publication in professional journals. I authorize Falls Orthodontics doctors to share patient treatment information when collaborating with dentists and other healthcare professionals as appropriate and to bill insurance for procedures performed, or to inquire about estimated treatment.

I authorize payment to Cheryl K. Cermin, DDS for the group insurance benefit otherwise payable to me for any services rendered.

I, the above-named responsible party, understand the above information is necessary to provide the above named patient with orthodontic care, I have answered all questions to the best of my knowledge and I will notify this dental care facility of any and all changes regarding health, health care providers, or medications. I consent to the performing of dental procedures agreed to be necessary or advisable.
Signature*Date*

I have read and agree to the HIPAA form posted at www.fallsorthodontics.com, or have reviewed the HIPAA form in the office. *

Yes No

Sign below if you agree to our HIPAA Policy.

Clear

Date

Thank you so much for your time! We look forward to seeing you soon! :)

Dr. Cheryl K. Cermin Dr. Andrew M. Orchin Dr. Jill M. Orchin

Welcome to Falls Orthodontics!

Pediatric Sleep Questionnaire