New Patient Forms

New Patient - Child Form

We would like to welcome you to the office of Dr. Kimi S. Caswell. Our staff is dedicated to providing excellence in orthodontic care.
CHILD INFORMATION

Please tell us a little about yourself.
Name

First Name Last Name
Preferred Name
Sex *

M F Other
Address *

Address

Street Address Line 2

City State / Province

Zip
Date of Birth *

Month Day Year
Date
Age *
School
Grade
Hobbies & Interests
Phone Number *
808-123-4567
Mobile or Home *

Mobile Home
Email *
example@example.com
Who does this email belong to? *
Would you like email/text appointment reminders?

Yes No
Have we seen any of your relatives in our office?

Yes No
If yes, please list names:
How do you feel about wearing braces or Invisalign?
Do you have any friends who wear braces or Invisalign?
What is your primary concern for today's visit? *
How did you hear about our office? *
Which office is most convenient for you? *

Honolulu Kahala Mililani
FAMILY INFORMATION
PARENT 1
Name *
First Name and Last Name
Is address same at child's?

Yes
Address (If different)

Street Address

City

Postal / Zip Code
Phone Number *
808-123-4567
Mobile or Home? *

Mobile Home
Date of Birth *

Month Day Year
Date
Dental Insurance *
HDS, HMSA, Delta Dental, etc. (If none, write No Insurance)
Insurance Member #
Occupation
Employer
PARENT 2
Name
First Name and Last Name
Is address same at child's?

Yes
Address (If different)

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number
808-123-4567
Mobile or Home?

Mobile Home Type option 3
Date of Birth

Month Day Year
Dental Insurance
HDS, HMSA, Delta Dental, etc. (If none, write No Insurance)
Insurance Member #
Occupation
Employer
Parents are:

Single Married to each other Divorce or separated from each other
Name of Person Responsible for Account *
Relationship to Patient *
CHILD'S HEALTH HISTORY
Name of Physician
Are you in good health? *

Yes No
If no, please explain:
Have you been hospitalized or had operations? *

Yes No
If yes, please describe:
Do you have any allergies? *

Yes No
If yes, please list allergies:
Are you currently taking any medications? *

Yes No
If yes, please list medications:
Who do you resemble most? *

Mom Dad
Have you begun puberty? *

Yes No
If yes, what age?
Have you had tonsils and adenoids removed? *

Yes No
If yes, what age?
Are you allergic to LATEX products? (i.e. gloves, balloons) *

Yes No
If yes, please describe allergy:
Do you have frequent colds, sore throat, canker sores? *

Yes No
If yes, please describe:
Do you have frequent headaches or muscle soreness around the head and neck? *

Yes No
If yes, how do you treat the pain?
Have you been diagnosed or treated for any of the following? Check all that apply:

Diabetes High Blood Pressure Convulsions Tuberculosis Heart Trouble Epilepsy Herpes Hepatitis Drug allergy HIV Blood disorders Rheumatic Fever Venereal Disease Asthma Pneumonia Fainting Endocrine problems AIDS
Please explain above conditions or list other medical conditions:
DENTAL HISTORY
Name of General Dentist *
Date of last visit

Month Day Year
Date
What was done?
Check up, cleaning, fillings, crown, etc.
Are any teeth sore today? *

Yes No
If yes, please explain:
Have you had any injuries to the face, mouth or teeth? *

Yes No
If yes, please explain:
Have you ever sucked your fingers or thumb? *

Yes No
If yes, until what age?
Do you breathe primarily through your mouth? *

Yes No
Do you clench or grind your teeth? *

Yes No
If yes, please explain:
Is there clicking or pain on opening or closing the mouth? *

Yes No
If yes, please explain:
Parent/Guardian Signature: *

Clear
Date *

Month Day Year
Date
Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- involved in that treatment directly and indirectly.
- Obtain payment from third - party payer, (insurance carriers etc
- Conduct normal healthcare operations.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this practice has the right to chance its Notice of Privacy Practices from time to time and that I may contact this practice at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient Name
Parent/Guardian Name
Relationship to Patient
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Patient Photo / Video Release Form

This release is designated to give permission to Dr. Kimi S. Caswell, D.D.S., M.S. to use my photos / videos for educational and promotional purposes. I allow my digital patient photo / video series as well as any photos / videos taken in-office or at patient appreciation events to be shared with others by means of internet and print media including but not limited to: our business website, social media websites and print advertising. Dr. Caswell has permission to use my photos / videos in this manner unless I request that she no longer use them. I understand that I have the option to decline this request, and am not obligated in any way to provide permission to use these photos / videos.

I allow Dr. Kimi S. Caswell, D.D.S., M.S. to use my photos / videos for educational and promotional purposes.
Patient Name
Parent/Guardian Name
Relationship to Patient
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty:

New Patient - Child Form

CHILD INFORMATION

FAMILY INFORMATION

PARENT 1

PARENT 2

CHILD'S HEALTH HISTORY

DENTAL HISTORY