Orthodontic Questionnaire for Children
Welcome to Palmetto Smiles! Please fill out all pages on this form to the best of your ability so that we may prepare for your child's first appointment.
Patient name
*
First Name
Last Name
Preferred name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Primary contact
*
-
Area Code
Phone Number
This phone number is
*
Home phone
Mom's cell
Dad's cell
Patient's cell
Email address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child lives with
*
Both parents
Mother
Father
Grandparent
Any siblings who are patients of Palmetto Smiles?
*
Back
Next
Father/Guardian's full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Address (if different than child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of employment
*
Phone number
*
-
Area Code
Phone Number
Work number
-
Area Code
Phone Number
Driver's license number
*
Back
Next
Mother/Guardian's full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Address (if different than child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of employment
*
Phone number
*
-
Area Code
Phone Number
Work number
-
Area Code
Phone Number
Driver's license number
*
Back
Next
Whom may we thank for referring you to our office?
*
Please enter full name of doctor, school, website or person.
What is your biggest concern with your child's bite/smile?
Name of closest relative or friend not residing with patient who we may contact in case parents cannot be reached
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
As parent or guardian of the above named child, I give my consent to needed dental services and use of proper and acceptable methods to complete a dental exam. I authorize release of any and all information: radiographs, photographs and models. I also allow for photographs to be used at the discretion of Palmetto Smiles. I also accept responsibility of payment of the services provided for my child. For the safety of my child, I will remain at the office during my child's visit in case I am needed by staff.
*
Parent/guardian's signature
Clear
Date
*
-
Month
-
Day
Year
Date
Back
Next
Medical History
Child's physician
*
Phone Number
-
Area Code
Phone Number
Date of last exam
*
-
Month
-
Day
Year
Date
Is your child allergic to any medicines or foods?
*
No
Is your child taking any medications?
*
No
Has your child ever been hospitalized or had an operation?
*
No
Does your child have any physical, mental, emotional or muscular disabilities?
*
No
Does your child have any hearing, sight, speech or learning problems?
*
No
Does your child need an antibiotic prescription (recommended by your phyysician for a heart condition - artificial valves/shunts, etc.) before any dental work?
*
No
Yes
Please check any that pertain to your child
*
None
Heart/cardiovascular condition
Liver/kidney problem
Bleeding disorder
Epilepsy
ADD/ADHD
Allergies
Asthma
Hepatitis
Diabetes
Cerebral Palsy
Rheumatic Fever
Heart murmur
Sickle Cell Anemia
HIV/AIDS
Eczema/skin disorders
Autism
Back
Next
Dental History
Who is your child's primary dentist?
*
When was their last visit to the dentist?
*
-
Month
-
Day
Year
Date
Were any x-rays taken?
*
Yes
No
Unsure
Is your child experiencing dental pain today?
*
No
Has your child experienced an unfavorable reaction from previous dental care?
*
Yes
No
How often does your child brush his/her teeth?
*
How often does your child floss his/her teeth?
*
Does your child have a...
*
Thumb habit
Pacifier habit
Finger habit
None
Do you have well water?
*
Yes
No
Does your child take fluoride supplements?
*
Yes
No
Does your child take a bottle at night?
*
Yes
No
I have read my child's medical history and confirm that it accurately states past and present conditions
*
Parent/Guardian signature
Clear
Date
*
-
Month
-
Day
Year
Date
Back
Next
Primary Dental Insurance Only
Please note we are not a participating or contracted provider with any insurance plan. We will verify your orthodontic benefit for you prior to your consultation.
Insured's name
First Name
Last Name
Insured's date of birth
-
Month
-
Day
Year
Date
Insured's SS#
Employer
Insurance company name
Group/Policy #
Claims phone number
-
Area Code
Phone Number
Claims address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Office Policies
Please click the link, review our office policies and sign below to indicate you have read and understand our policies.
Parent/Guardian Signature
Clear
Back
Next
Acknowledgement of Receipt of Notice of Privacy Practices
You may refuse to sign this acknowledgement. Please click the link, read and sign below to indicate you have read and understand the Notice of Privacy Practices.
I,
Parent/Guardian's name
, have received a copy of this office's Notice of Privacy Practices.
Signature
Parent/Guardian's signature
Clear
Back
Next
Authorization Compound
This authorization form permits Palmetto Smiles 139 Whiteford Way Lexington, SC 29072 to use or disclose protected health information listed in the description sections below to the Entity or Person listed in each section.
Patient name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Voicemail/text/email authorization (We need at least one form of contact)
School/Employee Authorization
Other authorization (Grandparents, Aunt/Uncle, Friend, etc.)
General viewing and social media viewing
Photos - Office Placement
Comments
Contest Information
The purpose of this authorization is to meet the patient's request for information disclosures and uses. Expirations date or event: this authorization shall be enforced until revoked by the patient. Verification method or code: This practice will verify the identity of any entity requesting protected health information. Verification may include patient's date of birth:
-
Month
-
Day
Year
Patient's date of birth
Rights of the patient: I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form. I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to disclosure by the recipient and may no longer be protected by federal or state law.
Signature of Parent/Guardian or Personal Representative (as defined by HIPAA)
Clear
Date
-
Month
-
Day
Year
Date
SUBMIT FORMS
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm