Welcome to the Orthodontist

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.
Child's Name*

FirstLast
Child's Birthdate

MonthDayYear
Age of Patient

ChildAdult
Parent's Email*
School:
General Dentist:
General Dentist Phone Number

Area CodePhone Number
General Dentist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician
Physician Phone Number

Area CodePhone Number
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we Thank for referring you?
Person Responsible for Account
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Parent/Guardian Primary Information
Name

First NameLast Name
Birthdate

MonthDayYear
Address (if different from patients)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone #

Area CodePhone Number
Phone

Area CodePhone Number
Employer
Parent/Guardian 2 Primary Information
Name

First NameLast Name
Birthdate
Address (if different from patients)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Work Phone #

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

DoctorMailerOtherFriendYellow Pages
Medical History
Height
Weight
General Health

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

Rows	Yes	No
Adenoids (removed)
Allergies
Asthma
Diabetes
Epilepsy
Heart Disorders
HIV +/AIDS
Rheumatic / Scarlet Fever
Blood Disorders
Measles
Healing Ability
Hospitalized for Sickness or Injury
Injuries
Is Patient under Treatment at this time
Medication now being taken
Mumps
Tonsils (removed)
X-ray Treatment (Not Diagnostic)

Please Describe any Problems that concern you Orthodontically
Is patient covered by dental insurance?

YesNo
If yes, which carrier?*
Is patient covered by secondary dental insurance?

YesNo
If yes, which carrier?
Has the patient had previous orthodontics consultations or treatments?

YesNo
If so, on what date?
Name

First NameLast 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.
I agree to the above terms and conditions*

YesNo
Should be Empty:

Westside Orthodontics

Parent/Guardian Primary Information

Parent/Guardian 2 Primary Information

Medical History