• Health History Form and Privacy Practices Acknowledgement - Child

  • Thank you for scheduling an appointment at Montgomery Orthodontics. Prior to your child's first appointment, please complete Sections 1 - 10 of this form.

    The information you provide will be sent to our office with secure encryption. Our office complies with HIPAA Privacy requirements (see Section 8 of this form). Completion of this form prior to your child's appointment will save you time during your visit to our office and will allow us to verify your insurance coverage.

    You can expect that it will take approximately 10 - 15 minutes to complete this form. If you have any questions, please call our office at (609) 688-1611.

    We look forward to seeing you and your child.

  • Section 1: Patient Information

    Please complete the following information for your child
  • 4. Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 2: Parent/Guardian/Responsible Party 1 Information

  • 2. Relationship to Patient*
  • 4. Responsible for scheduling appointments for the Patient?*
  • 5. Current Marital Status*
  • 6. Is Responsible Party 1 Mailing Address the same as Child Mailing Address?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 12. Preferred Phone Number*

  • Section 3: Parent/Guardian/Responsible Party 2 Information

  • 1. Is there another parent, guardian, or responsible party for the child patient?*
  • 3. Relationship to Patient*
  • 4. Financially responsible for treatment rendered at this office for the Patient?*
  • 5. Responsible for scheduling appointments for the Patient?*
  • 6. Current Marital Status*
  • 7. Is Responsible Party 2 Mailing Address the same as Child Mailing Address?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 13. Preferred Phone Number*

  • Section 4: Primary Orthodontic Insurance Information

  • 1. Do you have primary orthodontic insurance coverage?*
  • 3. Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. Check any that apply:*
  • 8. Plan Type*
  • Format: (000) 000-0000.

  • Section 5: Secondary Orthodontic Insurance Information

  • 1. Do you have secondary orthodontic insurance coverage?*
  • 3. Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. Check any that apply:*
  • 8. Plan Type*
  • Format: (000) 000-0000.

  • Section 6: Patient Medical History

  • 1. Does your child have a Physician?*
  • 3. Approximate date of your child's last physical exam*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • 6. Is your child currently taking any medication*
  • 8. Is your child allergic to latex?*
  • 9. Is your child allergic to any medication*
  • 11. Is your child allergic to metals?*
  • 13. Does your child have a history of any medical illness?*
  • 15. Has your child had any surgeries?*
  • 17. Has your child ever been involved in a serious accident?*
  • 19. Please check any of the following that applies to your child. If none of these apply to your child, please check "NONE OF THE ABOVE"*
  • 20. Has puberty begun?*
  • 21. How would you describe your child's current health (good, fair, or poor)?*

  • Section 7: Patient Dental History

  • 1. Does your child have a dentist?*
  • Format: (000) 000-0000.
  • 5. Approximate date of your child's last visit to the Dentist*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 6. Approximate date of your child's last Dental X-Rays*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. Has your child had a panoramic x-ray taken?*
  • 8. Approximate date of last panoramic x-ray*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 10. Has your child ever had or been evaluated for orthodontic treatment?*
  • 12. Does your child like their smile?*
  • 14. What are you most interested in learning more about for your child?*
  • 15. Does your child have dental implants?*
  • 16. Does your child have any unfinished or planned dental work?*
  • 18. Has your child experienced trauma to their teeth or jaw?*
  • 20. Please indicate any temporomandibular joint problems that apply to your child. If none of these apply to your child, please check "NONE OF THE ABOVE"*
  • 21. Has your child ever had any temporomandibular joint therapy?*
  • 22. Has your child ever had jaw surgery?*
  • 23. Does your child wear a night guard?*
  • 24. Has your child ever had speech therapy and/or myofunctional therapy?*
  • 26. Has your child had any of their wisdom teeth removed?*
  • 27. Do your child's gums ever bleed?*
  • 28. Has your child been treated for periodontal disease?*
  • 29. Does your child require antibiotics before dental procedures?*
  • 30. Does your child require a mouth guard?*
  • 31. Does your child brush their teeth daily?*
  • 32. Does your child floss their teeth daily?*
  • 33. Describe your child's current dental health (good, fair, or poor)?*
  • 34. Please check anything below that applies to your child. If none of these apply to your child, please check "NONE OF THE ABOVE"*
  • 36. How would you describe your child's expected level of cooperation with orthodontic treatment*

  • Section 8: HIPAA Notice of Privacy Practices

  • Please review the following Notice of Privacy Practices

  • Section 9: Authorization and Acknowledgement

  • By clicking "Submit",

    • I understand that the information I have given is correct to the best of my knowledge, and is accessed only via a secure, encrypted interface.
    • I understand that it is my responsibility to inform Montgomery Orthodontics of any changes to the information I provided on this form.
    • I consent to share dental records from Montgomery Orthodontics with my child's dentist and/or dental professionals for purposes of Patient care.
    • I consent to receive appointment reminders via text message and/or email. I may opt-out of this at any time by notifying Montgomery Orthodontics.
    • I understand that I am responsible for full payment of services rendered and also responsible for paying any co-payments and deductibles that my insurance does not cover. I am responsible for notifying Montgomery Orthodontics of any changes in my insurance coverage.
    • I understand and have read the Notice of Privacy Practices provided in Section 8 of this form and that I may request a copy of such policy at any time.
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 10: Submit the form

  • Should be Empty: