Child Patient Form
01: Tell Us About Your Child
Child's Name:
*
First Name
Last Name
Nickname:
Gender:
Male
Female
School:
Hobbies/Sports:
Child's Birthday
-
Month
-
Day
Year
Date
Child's Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
02: Who is Accompanying Your Child Today?
Name:
First Name
Last Name
Relationship:
Do You Have Legal Custody of This Child?
Yes
No
Whom May We Thank for Referring You?
List Brothers/Sisters With Age:
General Dentist:
Last Visit Date:
-
Month
-
Day
Year
Date
Parent's Marital Status
Single
Married
Widowed
Divorced
Separated
03: Parent's Information
Mother's Name:
First Name
Last Name
Please Select One:
Biological Mother
Step Mother
Guardian
Employer:
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number:
Driver's License Number:
Father's Name:
First Name
Last Name
Please Select One:
Biological Father
Step Father
Guardian
Employer:
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number:
Driver's License Number:
04: Person Responsible for Account
Name:
First Name
Last Name
Relationship:
Billing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Employer:
Social Security Number:
Driver's License Number
Birthdate:
-
Month
-
Day
Year
Date
Name of Person Responsible for Making Appointments
First Name
Last Name
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
05: Primary Orthodontic Insurance
Do You Have Orthodontic Coverage?
Yes
No
Insurance Company Name:
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Group # (Plan, Local or Policy #):
Insured's Name
First Name
Last Name
Relationship to Patient:
Insured's Birthday
-
Month
-
Day
Year
Date
Insured's Social Security Number:
Insured's Employer
Do You Have Secondary Orthodontic Insurance?
Yes
No
Secondary Insurance Company Name:
Secondary Insurance Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance Company Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Insurance Group # (Plan, Local or Policy #):
Insured's Name:
First Name
Last Name
Relationship to Patient:
Insured's Birthday
-
Month
-
Day
Year
Date
Insured's Social Security Number:
Insured's Employer:
06: Medical History
What are the main concerns that you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?
Yes
No
Has there been any injuries to the face, mouth, teeth or chin?
Yes
No
List any musical instruments played:
Yes
No
Have adenoids or tonsils been removed?
Yes
No
Has your child been informed of any missing or extra permanent teeth?
Yes
No
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Yes
No
Does your child brush his/her teeth daily?
Yes
No
Floss his/her teeth daily?
Yes
No
Childʼs Physician:
Physician Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Visit:
-
Month
-
Day
Year
Date
Is your child currently under the care of a physician?
Yes
No
Has puberty begun?
Yes
No
Has menstruation begun? (Girls)
Yes
No
Please describe your childʼs current physical health:
Good
Fair
Poor
Please list all drugs that your child is currently taking:
Please list all drugs that your child is allergic to:
07: Medical History
Has your child ever had any of the following medical problems?
Allergic to Plastic
Heart Murmur
Cancer
Diabetes
Rheumatic Fever
HIV+/AIDS
Hemophilia
Asthma
Hepatitis
Tuberculosis (TB)
Allergic to Latex/Metals
Congenital Heart Defect
Convulsions/Epilepsy
Abnormal Bleeding
Hearing Impairment
Any Operations
Any Stays in the Hospital
Kidney/Liver Problems
Handicaps/Disabilities
Allergies to Any Drugs
Please discuss any medical problems that your child has had:
08: Habits
Does your child have any of the following habits?
Thumb/Finger Sucking
Lip Sucking/Biting
Clenching/Grinding Teeth
Nursing Bottle Habits
Mouth Breather
Speech Problems
Nail Biter
Tongue Thrust
09: Insurance Authorization
I authorize the insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits.I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature of Parent or Guardian
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: