New Patients (Child)
Which location would you prefer?
Cupertino
Los Altos
Patient Information
Patient's Name
*
First Name
Last Name
Nickname (if preferred)
Gender
*
Male
Female
Patient's Date of Birth
-
Month
-
Day
Year
Date
Parent E-mail
*
example@example.com
Phone/Cell
*
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about our office?
Have we treated another member of your family?
Yes
No
What are your main orthodontic concerns that you would like to be addressed?
*
Has the patient visited an orthodontist before?
*
Yes
No
Currently in Treatment with another orthodontist
Other
If so, is this a second opinion or is treatment completed?
Who is filling in this form?
*
Relationship
*
Do you have legal custody?
*
Yes
No
Father's Information
Name
First Name
Last Name
Marital Status
Single
Married
Widowed
Divorced
Separated
Domestic Partner
Mother's Information
Name
First Name
Last Name
Marital Status
Single
Married
Widowed
Divorced
Separated
Domestic Partner
Dental & Medical History
Name of General Dentist
Last Visit with Dentist
Has your child had a Panoramic X-ray (full mouth) taken in the last 6 months?
Yes
No
If yes, where was it taken so we can reach out to obtain a copy.
What is the name of your dental insurance? (if covered)
Is your child currently under the care of a physician (outside of normal annual visits)?
*
Yes
No
If 'Yes', please explain
History of Major Illness?
*
Yes
No
If 'Yes', please explain
Any sensitivities or allergies?
*
Yes
No
If 'Yes', please explain
Currently taking any medications?
*
Yes
No
If 'Yes', please explain
Has Puberty Begun?
*
Yes
No
Has Menstruation (period) Begun?
*
Yes
No
Has your child been diagnosed or treated for any of the following conditions?
Arthritis
*
Yes
No
Asthma
*
Yes
No
ADD, ADHD
*
Yes
No
Autism
*
Yes
No
Blood disorder
*
Yes
No
Cancer
*
Yes
No
Diabetes
*
Yes
No
Epilepsy
*
Yes
No
Heart Condition
*
Yes
No
Hearing Impairment
*
Yes
No
Hepatitis
*
Yes
No
HIV/AIDS
*
Yes
No
Nervous Disorder
*
Yes
No
Sleep Apnea/Sleep Disorder
*
Yes
No
Tuberculosis
*
Yes
No
Does your child require antibiotics before dental treatment?
*
Yes
No
Have the adenoids or tonsils been removed?
*
Yes
No
Have you been informed of any missing or extra permanent teeth?
*
Yes
No
Have there ever been injuries to your child's face, mouth or chin?
*
Yes
No
Has your child ever had pain/tenderness in the jaw joint (TMJ/TMD)?
*
Yes
No
Does/Did your child have any of the following habits?
Grinding Teeth
*
Yes
No
Chronic Mouth Breathing
*
Yes
No
Finger/Thumb Sucking
*
Yes
No
Speech Problems
*
Yes
No
Prolonged Bottle/Pacifier
*
Yes
No
Chewing/Eating Problems
*
Yes
No
Please list any other condition that you want us to be aware of:
Do you give the office of Dr. Setareh Mozafari permission to send your records (X-ray and photos) to your dentist?
*
Yes
No
Dental Insurance
We will be happy to verify your Dental Insurance for Orthodontic benefits prior to your Consultation appointment. If you wish so, please complete this section.
Insurance Carrier
Employer's Name
Subscriber First and Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Member ID
Group
Please agree to the following
*
I understand that the information that I have provided 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 my child’s medical status. I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.
Signature
Submit
Should be Empty: