Medical History Form

New Patient Information

Child Intake Form
Patient full name:*

First NameLast Name
Patient preferred name:
Patient date of birth:*

MonthDayYear
Patient gender:*

MaleFemale
Identifies as:
If different than gender
Patient preferred pronouns:
Patient's school:*
School grade:
Who does the patient primarily live with:*
PARENT'S Marital Status:*
Primary Contact Name:*

First NameLast Name
Primary Contact Relation:*
Primary phone number:*

Area CodePhone Number
Primary phone number type:*
Primary Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code
Primary email address:*
example@example.com
Secondary contact name:
Secondary contact relation:
Secondary phone number:

Area CodePhone Number
Secondary phone number type:
Secondary contact address (IF different than the primary address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary email address:
example@example.com
Have any immediate family members been treated at our office?*

YesNo
Please list current and previously treated immediate family members:
Please list names and relationship to patient
Who do you want to receive reminders?*
Financial Details

If insurance is applicable, PLEASE complete all of the insurance questions.
Who will be financially responsible for this account?*
(self, parents, father, mother, other)
Financially responsible party name:*
Financially responsible party street address (IF different from patient)

Street Address

Street Address Line 2

CityProvince

Postal Code
Financially responsible party primary phone:*

Area CodePhone Number
Phone number type*
Financially responsible party spouse name:
To help us prepare in advance, please provide your insurance information. If you are covered under more than one plan, please include all applicable details. Having this information on file ahead of your appointment helps ensure a smooth visit and avoids any delays in getting started with treatment.
Do you have insurance? (If yes, the next following questions are required)*
Please upload a photo/screenshot of your insurance card to confirm the policy and ID numbers.*

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PLEASE MAKE SURE YOU ARE PROVIDING A DENTAL CARD AND NOT A MEDICAL CARD Cancelof
Group number:*
ID number:*
Primary insurance provider:*
Insurance company
Primary policy holder's name: *
First & Last
Policy holder's date of birth:*

MonthDayYear
Date
Primary's relationship to patient:*
Mother, Father, Step-parent, Self
Primary employer:*
Business/company name
Primary employer's address:*
Business/company address
Primary employer's phone:*

Area CodePhone Number
Do you have a secondary insurance to add?:*
*Only required if there is a SECONDARY insurance plan* Please upload a photo/screenshot of your insurance card to confirm the policy and ID numbers.*

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Group number:*
ID number:*
Secondary insurance provider:*
Insurance Company
Secondary policy holder's name: *
First & Last
Policy holder's date of birth:*

MonthDayYear
Date
Secondary's relationship to patient:*
Mother, Father, Step-parent, Self
Secondary employer: *
Business/company name
Secondary employer's address:*
Business/company address
Secondary employer's phone:*

Area CodePhone Number
I hereby authorize release of any information relating to my insurance.*
Signature*
I hereby authorize payment of insurance benefits directly to Beam Orthodontics.*
Signature*
Date*

MonthDayYear
Date
Dental History
Does the patient currently have a dentist?*

YesNo
Dentist's first and last name, as there are multiple dental professionals with the same last name*
If the patient does not have a dentist, please type "N/A"
Dental practice name*
Last dentist visit*

MonthDayYear
If unsure of exact date, an approximate date is sufficient.
What was completed at the last dentist visit?*
If you currently do not have a dentist, we would be happy to recommend one as their services may be required for orthodontic treatment.
Have there been any injuries to the face or mouth?*
Please explain the injuries:
Has the patient ever had an oral habit? (Thumb, finger, soother?)*
What was the oral habit?
At what age did the habit stop?
Does the patient have a tongue thrust?*
Does the patient have any trouble with speech?*
Please explain the speech challenges:
Does the patient have a difficult time breathing through their nose?*
Rate the patient's oral hygiene:*
Is the patient flossing?*

RegularlyOnce in a whileRarely
Medical History
Is patient presently under a physician's care?*
Reason for patient being under physician care:
Does the patient have a history of any major illness, genetic disorder or developmental delay?*
Please explain:
Is the patient pregnant?*
Due date:

MonthDayYear
Does the patient snore?
Any problems with tonsils or adenoids?*
Have tonsils or adenoids been removed?*
At what age were the tonsils or adenoids removed?
Does the patient smoke?
Is the patient on any prescribed drugs or medications?*
List any drugs or medications currently being taken:*
Reason for medication:*
Please list any allergies and/or drug sensitivities:
Are there any other medical diagnoses we should be aware of?*
Please explain further:
Orthodontic Goals
What is your primary Orthodontic concern?*
What orthodontic treatment option(s) interest you?*

Clear AlignersMetal BracesRetainers onlyIf Other, please explain:Other
If Orthodontic treatment is recommended, how soon would you like to get started?*

ASAPWithin a MonthWithin 6 MonthsIf Other, please explain:Other
How did you learn about our practice or whom may we thank for referring you?*

Referred by DentistFamily/FriendGoogleInstagramFacebookIf Other, please list source:Other
Consent

I understand that the information I have given is correct, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes. I authorize the orthodontic staff to perform necessary diagnostic and orthodontic procedures. During the initial orthodontic examination, video or photographs may be taken for clinical documentation and training purposes. By signing this form, you provide consent for this use. If you prefer not to have video taken during your examination, please inform your treatment coordinator directly.
Signature of responsible party*
Should be Empty:

New Patient Information

Financial Details

Dental History

Medical History

Orthodontic Goals

Consent