Patient Medical History Form(Child)

Welcome to PERILLO ORTHODONTICS
Patient Information
Today's Date*

MonthDayYear
Date
Patient Gender*
Patient Name*

First NameLast Name
Nickname
Patient Birth Date*

MonthDayYear
School
Grade
Hobbies/Sports
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we Thank for referring you?*
List siblings with ages*
General Dentist*
Last Dental Visit Date*

MonthDayYear
Date
Parent's Information
Parent 1/Account holder*

MotherFatherStep MotherStep FatherGuardian
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address same as child?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Email*
example@example.com
Parent 2*

MotherFatherStep MotherStep FatherGuardianN/A
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address same as child?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Parent's Marital Status*

N/ASingleMarriedDivorced
Who should be contacted for appointment reminders?*

Parent 1Parent 2
Primary Dental Insurance Information
Orthodontic Coverage*

YesNo
Insurance Company Name*
Insurance Phone Number*
Claim Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policyholder*

Parent 1Parent 2Other
Policyholder Name*

First NameLast Name
Policyholder Date of Birth*

MonthDayYear
Date
Policyholder Social Security Number*
Policyholder Employer*
Policy ID number*
Policy Group number*
Please provide a picture of the front and back of your insurance card

Either take or upload a photo
Take a photo of the FRONT of your insurance card
Take a photo of the BACK of your insurance card
OR
Upload a photo of the FRONT of your insurance card

Browse Files

Cancelof
Upload a photo of the BACK of your insurance card

Browse Files

Cancelof
Secondary Dental Insurance Information
Orthodontic Coverage*

YesNo
Insurance Company Name*
Insurance Phone Number*
Claim Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy holder*

Parent 1Parent 2Other
Policy holder Name*

First NameLast Name
Policy holder Date of Birth*

MonthDayYear
Date
Policy holder Social Security Number*
Policy holder Employer*
Policy ID number*
Policy Group number*
Please provide a picture of the front and back of your insurance card

Either take or upload a photo
Take a photo of the FRONT of your insurance card
Take a photo of the BACK of your insurance card
OR
Upload a photo of the FRONT of your insurance card

Browse Files

Cancelof
Upload a photo of the BACK of your insurance card

Browse Files

Cancelof
Patient Medical History
What are the main concerns that you would like orthodontics to accomplish?*

Are you allergic to any of the following?*

	YES	NO
LATEX
METAL
PLASTIC

Please list any drugs/materials that you are allergic to:
Has your child ever been evaluated for orthodontic treatment?*

YesNo
Has your child ever had orthodontic treatment?*

YesNo
Have there been any injuries to the face, mouth, teeth or chin?*

YesNo
Have adenoids or tonsils been removed?*

YesNo
Does your child have any missing or extra permanent teeth?*

YesNoUnknown
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

YesNo
Does your child brush his/her teeth daily?*

YesNo
Does your child floss his/her teeth daily*

YesNo
List any musical instruments played:

Does your child do/have any of the following?*

	YES	NO
CLENCH/GRIND TEETH
MOUTH BREATHING
SPEECH PROBLEMS
TONGUE THRUST
LIP SUCKING/BITING
NAIL BITING
THUMB/FINGER SUCKING

Please describe your child's current physical health:*

GoodFairPoor
Please list any current medications.
Physician Name/Phone number and Date of last visit

Has your child ever had any of the following medical problems? (Please check all that apply)*

	YES	NO
ASTHMA
ADD/ADHD
CANCER
ABNORMAL BLEEDING
DIABETES
EMOTIONAL DISORDER
EPILEPSY/SEIZURES
FAINTING SPELLS
ARTIFICIAL BONES/JOINTS/VALVES
CONGENITAL HEART DEFECT
RHEUMATIC FEVER
HIGH BLOOD PRESSURE
ULCERS
HEPATITIS
KIDNEY DISEASE
LIVER DISEASE
FEVER BLISTERS/HERPES
TUBERCULOSIS
NEUROLOGICAL DISORDERS
HANDICAPS/DISABILITIES
HEART MURMUR
BLOOD TRANSFUSION
RHEUMATOID ARTHRITIS
HEMOPHILIA
HIV/AIDS
SEVERE/FREQUENT HEADACHES
SICKLE CELL DISEASE
SINUS PROBLEMS
HOSPITALIZED FOR ANY REASON

Other illnesses:
Please explain any YES answers
Please list any drugs that your child is currently taking
Include other comments regarding your child's Medical History
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 my medical status. I authorize the dental staff to perform the necessary dental services that I may need.
Signature*

Clear
INSURANCE ASSIGNMENT: If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. If my insurance was to terminate or there is a lapse in coverage, I understand that I would become responsible for the balance that my insurance does not pay. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all of my insurance submissions, whether manual or electronic.
Signature*

Clear
PHOTO RELEASE: Perillo Orthodontics has my permission to use my photograph publicly to celebrate the practice. I understand that the images may be used in print publications, online publications, websites and/or social media. I also understand that no royalty, fee or any compensation shall become payable to me for any reason for such use.
I agree to the above terms regarding photo release*

YesNo
Signature*

Clear
Should be Empty:

Patient Information

Parent's Information

Primary Dental Insurance Information

Please provide a picture of the front and back of your insurance card

OR

Secondary Dental Insurance Information

Please provide a picture of the front and back of your insurance card

OR

Patient Medical History