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.
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Information must be filled out completely

Custodial Parent Information
Relationship *
Additional Parent Information
Primary Orthodontic Insurance
Secondary Orthodontic Insurance
What are the main concerns you would like orthodontics to address?
Have adeniods or tonsils been removed?
Have you or your child been informed of any missing or extra permanent teeth?
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? (It is required to fill out each one in this section in order to complete and submit this form).
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 *
Tungue 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 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.
I Agree to the above terms and conditions *