• Child New Patient Form

  • Patient Information

  • Gender
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Have we treated any additional family members?

  • Parent/Guardian Information

  • Parents' Marital Status*
  • Parent/Guardian Type*
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Patient lives with:*
  • Format: (000) 000-0000.
  • Is this parent/guardian financially responsible for this account?

  • Second Parent/Guardian Information

  • Second Guardian Type
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental Insurance Information

    (If you have it)
  • Format: (000) 000-0000.
  • Date of Birth
     - -

  • Secondary Dental Insurance

    (If you have it)
  • Format: (000) 000-0000.
  • Date of Birth
     - -

  • Medical Insurance

  • Format: (000) 000-0000.
  • Date of Birth
     - -

  • Motivation for Treatment: The Teeth

    If the child's teeth could be changed, how would you like them to change?
  • Make the upper front teeth
  • Move upper teeth
  • Move lower teeth
  • Make the line of the upper teeth more level

  • The Face

    If the child's facial appearance could be changed, what would you change?
  • Get rid of sag under lower jaw
  • Move chin
  • Move chin to center it
  • Move lower lip
  • Move upper lip
  • Move the area around my nose
  • Make the profile of my nose
  • Move the area under my eyes
  • Make my cheekbones
  • When my teeth are touching, make my lips
  • When my teeth are touching, make my lips not touch and roll out
  • Make my face more
  • Reduce my lower jaw behind my mouth

  • Symptoms

    If you want to reduce pain or discomfort where is it located? Please be specific about the location; select right side, left side or both if they apply.
  • In front of my ears
  • Below my ears
  • Above my ears
  • In my ears
  • Neck
  • Shoulders
  • Temples
  • Teeth
  • Sinuses
  • Eyes

  • Dental Information

    Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment your child receives from our office. This information is kept strictly confidential.
  • Does your child have a general dentist?*
  • Format: (000) 000-0000.
  • When was your child's last dental cleaning?*
  • Does your child have any pending or planned dental work to be completed?*
  • Did your child's dentist refer you to our office?
  • Has your child ever had a previous orthodontic exam?*
  • Has your child ever had previous orthodontic treatment?*
  • Now, or in the past, has your child had issues with any of the following: (please check all that apply, or choose NONE)*
  • Does your child currently have any areas of irritation (pain, sores) in or around their mouth?*
  • Has your child ever had any injury to their face, mouth, or teeth?*
  • Does your child now, have they ever, experienced pain or discomfort in their jaw (i.e. TMJ/TMD issues)?*

  • Medical Information

  • Is your child presently in good health?*
  • Is your child currently under the care of a physician?*
  • Does your child have a personal or family physician?*
  • Is your child currently taking any prescription or non-prescription medications or supplements?*
  • Does your child have any known allergies to any drugs or medications?*
  • Does your child have any non-medication related allergies?*
  • Has your child had any hospitalizations or major illnesses in the last 5 years?*
  • Have your child's tonsils or adenoids been removed?*
  • Does your child require antibiotic medicine prior to dental treatments?*
  • Are there any learning disabilities or extra help needed for instructions?*
  • Are there any other physical, mental, or medical issues we should be aware of?*

  • Medical History

  • Now, or in the past, has your child had: (please check all that apply or choose NONE)

  • Privacy Notice

  • Insurance Release and Agreement

    I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company. I understand that I am responsible for payment of services rendered as well as any co-payments or deductibles.
  • Date
     - -

  • Signature/Verification of Information

    I hereby state that I have read, understand and have truthfully, to the best of my ability answered all questions containted on this form. I will not hold my Orthodontist or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my Orthodontist of any changes in medical or dental health. I authorize the Orthodontist or their staff to perform any necessary dental services that I may need. I authorize this practice to share treatment with collaborating dentists, surgeons, or other professionals when appropriate.
  • Date
     - -
  • Location

  • Click submit to securely send this form to our practice. Please note that further signatures may be required in the office.
  • Should be Empty: