Patient Information
Braces Omaha Child New Patient Form
We would like to welcome you and your child to our Braces Omaha Our goal is to provide you with the highest quality orthodontic care available in Omaha in a fun and friendly environment. Trust your smile to the unparalleled expertise of Braces Omaha.
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Information must be filled out completely

Custodial Parent Information
Relationship *
Additional Parent Information
Primary Orthodontic Insurance
Secondary Orthodontic Insurance
Have adeniods or tonsils been removed? *
Have you or your child been informed of any missing or extra permanent teeth? *
Has your child ever had any pain or tenderness in the jaw joint (TMJ, TMD)? *
Does your child brush his/her teeth daily? *
Does your child floss his/her teeth daily? *
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Is your child currently under the care of a physician? *
Please describe your child's physical health *
Has your child ever had any of the following medical issues?
Abnormal Bleeding *
Allergies to any drugs *
Allergy to latex/metals *
Allergy to plastic *
Any Hospital Stays *
Any Operations *
Asthma *
Cancer *
Congenital Heart Defect *
Convulsions/Epilepsy *
Diabetes *
Handicaps/Disabilities *
Hearing Impairment *
Heart Murmur *
Hemophilia *
Hepatitis *
HIV + /AIDS *
Kidney / Liver Problems *
Rheumatic / Scarlet Fever *
Tuberculosis (TB) *
Does your child have any of the following habits?
Clenching/Grinding Teeth *
Nurse Bottle Habits *
Lip Sucking/Biting *
Speech Problems *
Mouth Breather *
Thumb / Finger Sucking *
Nail Biting *
Tongue Thrust *
Please list an emergency contact not living with you
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 Braces Omaha to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles, social media or promotional materials and are the property of Braces Omaha. I understand that where appropriate, credit bureau reports may be obtained.
I Agree to the above terms and conditions *