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  • Logo for Genuine Orthodontics serving Brentwood, TN and the greater Nashville, TN area

    Child Medical Dental History

    This form is confidential and recorded/stored securely

  • Patient Information

  • Gender*
  • Does your child have any siblings?*
  • Have any family members been treated at our office?*

  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Please send parent/guardian 1 appointment reminders by:
  • Is the address for parent/guardian 1 different than the child's?*
  • Format: (000) 000-0000.
  • Please send parent/guardian 2 appointment reminders by:
  • Is the address for parent/guardian 2 different than the child's?

  • Financial Responsibility

  • Format: (000) 000-0000.

  • Your Child's Dental Information

  • Does your child have a general or pediatric dentist?

  • Dental Insurance

  • Does your child have dental insurance?*
  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Does this policy have orthodontic coverage?
  • Does your child have a secondary dental insurance*
  • Format: (000) 000-0000.

  • Dental History

  • Rows
  • Has your child ever taken pre-treatment antibiotics for a dental procedure?*
  • Does your family have a history of unusual dental/orthodontic problems?

  • Orthodontic History

  • Has your child ever had orthodontic treatment before?*
  • Do you have a family history of a jaw size imbalance?*

  • Medical Information

  • Does your child have a primary care physician or pediatrician*
  • Does your child see other physicians?

  • Please list any other physicians your child sees


  • Has your child been hospitalized in the past 5 years?

  • Medical History

    Mark Yes, No, or Don't Know/Understand
  • Rows
  • Rows
  • Have your child's relatives ever had bleeding disorders, diabetes, arthritis, severe allergies, or other genetic medical conditions?*

  • Medication

  • Does your child take any medications, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements?*

  • Please list any medication, nutritional supplement, herbal medication or non-prescription medicines, including fluoride supplements that your child takes.

     taken for
    taken for
    taken for
    taken for
    taken for
    taken for
    taken for
    taken for

  • Does your child chew/smoke tobacco or vape?*
  • Does your child currently have (or ever had) a substance abuse problem?*

  • Releases and Waivers

  • Should be Empty: