DiMassa and Wenger Child New Patient Form

Westside Orthodontics

Child New Patient Form

Please bring your Dental Insurance Card to your exam appointment,

or print one off of your insurance company's website.

First Name *

Last Name *

Month of Birth *

Day of Birth *

Year of Birth *

Age *

School

Parents Email

General Dentist

Address

Phone

Physician

Address

Phone

Who may we thank for referring you to our office?

Person Responsible for Account

Home Address

Street Address

Address Line 2

City

State

Zip Code

Home Phone #

Cell Phone #

Parent/Guardian Primary Information

Name

Month of Birth

Day of Birth

Year of Birth

Address (If different from patients)

Work Phone #

Phone

Employer Name

Driver's License No.

Social Security Number

Parent/Guardian 2 Primary Information

Name

Month of Birth

Day of Birth

Year of Birth

Address (If different from patients)

Work Phone #

Cell Phone

Home Phone

Employer Name

Drivers License No.

Social Security Number

How else have you heard of us? (Check the box for all that apply) *

Medical History

Height

Weight

General Health

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

Adenoids (removed) *

Yes

No

Allergies *

Yes

No

Blood Disorders *

Yes

No

Chicken Pox *

Yes

No

Diabetes *

Yes

No

Epilepsy *

Yes

No

Healing Ability (Poor) *

Yes

No

Heart Disorders *

Yes

No

HIV + /AIDS *

Yes

No

Hospitalized for Sickness or Injury *

Yes

No

Injuries *

Yes

No

Is Patient Under Treatment at this TIme *

Yes

No

Measles *

Yes

No

Medication Now Being Taken *

Yes

No

Mumps *

Yes

No

Rheumatic / Scarlet Fever *

Yes

No

Tonsils (removed) *

Yes

No

X-Ray Treatment (Not Diagnostic) *

Yes

No

Please describe any problems that concern you Orthodontically:

Is patient covered by dental insurance?

Yes

No

If yes, which carrier? *

Is patient covered by secondary dental insurance?

Yes

No

If yes, which carrier?

Has the patient had previous orthodontics consultation or treatment?

Yes

No

If so, on what date?

Doctor's name?

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.

Yes

I Agree to the above terms and conditions *

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