Welcome to the Orthodontist

Decoteau Orthodontics
PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE
Childs Name

First NameLast Name
Nickname
CHILD PREFERS TO BE CALLED
Child's Birthdate

MonthDayYear
Child's Age
MaleFemale
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Childs Email
example@example.com
Child's Home #

Area CodePhone Number
Hobbies/Sports:
School Name:*
Grade*
List brothers/sisters with age:
Who is accompanying your child to their consultation?
Parent/Guardian Name

First NameLast Name
Relation
Do you have legal custody of this child?

YesNo
Whom may we thank for referring you to our office?
PARENT INFORMATION
PARENT/GUARDIAN #1:

MotherStep MotherGuardianOther
Responsible for account?

YesNo
Name

First NameLast Name
Birthdate
E-mail*
example@example.com
Social Security #
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #

Area CodePhone Number
Cell #

Area CodePhone Number
Cell Phone Provider
Employer Name and Address:
Occupation
PARENT/GUARDIAN #2:

FatherStep FatherGuardianOther
Responsible for account?

YesNo
Name

First NameLast Name
Birthdate
Email
example@example.com
Social Security #
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #

Area CodePhone Number
Cell #

Area CodePhone Number
Cell Phone Provider
Employer Name and Address:
Occupation
Parents Responsible Status:

MarriedSingleDivorcedSeparatedWidowedPartnered
Cell Phone #

Area CodePhone Number
Email:
DENTAL INSURANCE INFORMATION
Do you have orthodontic coverage? (If no, skip to next question)

YesNo
PRIMARY ORTHODONTIC INSURANCE
Insured's Name:
Birthdate:
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber ID #:
Group #:
Do you have dual coverage?

YesNo
SECONDARY ORTHODONTIC INSURANCE
Insured's Name:
Birthdate:
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber ID #:
Group #:
Do you have dual coverage?

YesNo
EMERGENCY CONTACT INFORMATION
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation to Patient:
MEDICAL HISTORY
Child's Physician
Date of Last Visit
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ALLERGIES
Is your child allergic to:

LatexMetalsNickelPlasticsOther
Please list other allergies
Is your child allergic to any medication?

YesNo
Please List:

Has your child ever had any of the medical conditions listed below:

	Yes
Abnormal Bleeding
Anemia
ADD
ADHD
Anemia
Artificial Bones/Joints/Valves
Asthma
Bone Disorders
Cancer/Tumor
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy/Seizures
Gastrointestinal Disorders
Hearing Impairment
Heart Problems/Murmur
Hemophilia
Hepatitis/Liver Problem
Herpes/Fever Blisters
High/Low Blood Pressure
HIV +/AIDS
Kidney Problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Psychiatric Problems
Radiation/Chemotherapy
Rheumatic Fever
Severe/Frequent Headache
Sinus Problems
Tuberculosis (TB)

Please answer yes or now to the questions below

	Yes	No	Please List
Is your child taking any medication? Please List:
Is there a history of a major illness? Please List:
Has your child had any operations or been involved in a serious accident? Please list:
Are there any handicaps/disabilities that we should be aware of?
Are there any handicaps/disabilities that we should be aware of?
Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY
General Dentist
Date of Last Visit

DayMonthYear
Date
What concerns you most about your child's teeth?
Is your child presently in any dental pain?*

YesNo
Has your child ever had any of the habits listed below:

Clenching TeethGrinding TeethLip SuckingLip BitingMouth BreathingNail BitingBottle HabitSpeech ProblemsThumb/Finger HabitTongue Thrust

Please answer these questions about your child's dental history*

	Yes	No
Has your child ever experienced any unfavorable reaction to dentistry?
Has your child ever been evaluated or had orthodontic treatment before?
Is your child sensitive or self-conscious about his/her teeth?
Has anyone in the family received orthodontic treatment?
Is any part of your child's mouth sensitive to temperature or pressure?
Have there been any injuries to the face, mouth, teeth or chin?
Has your child been informed of any missing or extra permanent teeth?
Do teeth or jaws ever feel uncomfortable first thing in the morning?
Does your child ever experience jaw clicking or popping?
Does your child experience "tension" headaches?
Does your child brush his/her teeth daily?

I have truthfully answered all the above questions and agree to inform this office of any changes in my child's medical or dental history. I understand that diagnostic records may be used for educational and promotional purposes. In addition, I authorize the Doctors of Decoteau Orthodontics and staff to perform the necessary dental services my child needs.

I understand that I am responsible for payment of services rendered and also for paying any co-payments and deductibles that my insurance does not cover. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
I acknowledge

yes
This office reserves the right to verify the credit status of patients and/or their parents prior to extending credit for orthodontic fees and may, at the discretion of the office, use the services of one or more credit reporting services.
Signature of guardian or parent

Clear
I grant Dr. Jay M. Decoteau, D.M.D., P.C. (AKA: Decoteau Orthodontics) the right to use my images for the purpose of advertising and marketing, including but not limited to, their website, local newspaper and magazine ads, Facebook and other social media, and any in office media. I release Dr. Jay M. Decoteau, D.M.D., P.C., from any claims that may arise regarding the use of my image.
I consent

YesNo
Patient's Name:

First NameLast Name
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Should be Empty:

Decoteau Orthodontics

PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

Who is accompanying your child to their consultation?

PARENT INFORMATION

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

ALLERGIES

DENTAL HISTORY