Patient Information

Child New Patient Form

We would like to welcome you and your child to our office. Our goal is to make everyones visit pleasant, stress free and educational. We pride ourselves in creating beautiful smiles that lasts a lifetime. We look forward to seeing you in the office.

First Name *

Last Name *

Name your child prefers to be called?

School

Grade

Date of Birth: Month/Day/Year *

Email address *

Special Interests, Sports or Hobbies *

Siblings Names and Date of Birth

General Dentist *

Date of Last Appointment * +

Who may we thank for referring you to our office? *

Home Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone # *

Cell Phone # *

Information must be filled out completely

Custodial Parent Information

Relationship *

Mother

Step Mother

Guardian

Father

Resposible party? *

Marital Status *

Name of Parent *

Parent DOB: Month/Day/Year *

Work Phone # *

Cell Phone *

Home Phone *

Employer Name *

Drivers License Number *

Social Security Number *

Additional Parent Information

Name

Parent 2 DOB: Month/Day/Year *

Home Phone *

Work Phone #

Cell Phone

Address (if different than custodial parent)

Employer Name

Drivers License Number

Social Security Number

Primary Orthodontic Insurance

Policy Holder’s First Name

Policy Holder’s Last Name

Month of Birth

Day of Birth

Year of Birth

Social Security Number

Employer Name

Insurance Company

Insurance Company Address

City:

Insurance Company Phone #

Group ID Number

Member ID

Relationship to Patient

Secondary Orthodontic Insurance

Policy Holder’s First Name

Policy Holder’s Last Name

Social Security Number

Month of Birth

Day of Birth

Year of Birth

Employer Name

Insurance Company

Insurance Company Address

City:

Insurance Company Phone #

Group ID Number

Member ID

Relationship to Patient

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

Parent

Child

Dentist

Has your child ever had or been evaluated for orthodontic treatment before? *

Have there been any injuries to the face, teeth, jaw, mouth or chin? Please explain *

Have adenoids or tonsils been removed? *

Yes

No

Have you or your child been informed of any missing or extra permanent teeth? *

Yes

No

If yes, which ones?

Has your child ever had any pain or tenderness in the jaw joint (TMJ, TMD)? *

Yes

No

Does your child brush his/her teeth daily? *

Yes

No

Does your child floss his/her teeth daily? *

Yes

No

Childs Physician *

Phone *

Date of last visit * +

Is your child currently under the care of a physician? *

Yes

No

Please describe your child's physical health *

Excellent

Good

Fair

Poor

Please list all medications that your child is currently taking and for what conditions

Please list any medications that your child is currently allergic to.

If your child is a girl, has menstruation begun? *

yes

no

Has your child ever had any of the following medical issues?

Abnormal Bleeding *

Yes

No

Allergies to any drugs *

Yes

No

Allergy to latex/metals *

Yes

No

Allergy to plastic *

Yes

No

Any Hospital Stays *

Yes

No

Any Operations *

Yes

No

Asthma *

Yes

No

Cancer *

Yes

No

Congenital Heart Defect *

Yes

No

Convulsions/Epilepsy *

Yes

No

Diabetes *

Yes

No

Handicaps/Disabilities *

Yes

No

Hearing Impairment *

Yes

No

Heart Murmur *

Yes

No

Hemophilia *

Yes

No

Hepatitis *

Yes

No

HIV + /AIDS *

Yes

No

Kidney / Liver Problems *

Yes

No

Rheumatic / Scarlet Fever *

Yes

No

Tuberculosis (TB) *

Yes

No

Does your child have any of the following habits?

Clenching/Grinding Teeth *

Yes

No

Nurse Bottle Habits *

Yes

No

Lip Sucking/Biting *

Yes

No

Speech Problems *

Yes

No

Mouth Breather *

Yes

No

Thumb / Finger Sucking *

Yes

No

Nail Biting *

Yes

No

Tongue Thrust *

Yes

No

Please list an emergency contact not living with you

Name *

Phone *

Address *

City, State, Zip *

Agree To Terms

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.

Yes

I Agree to the above terms and conditions *

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