• Child New Patient Form

    Child New Patient Form

  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Primary Phone Type*

  • Parent/Guardian Information

  • Parent Marital Status*
  • Relationship with Patient*
  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Phone Type*
  • Format: (000) 000-0000.
  • Phone Type
  • Relationship with Patient*
  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Phone Type*
  • Format: (000) 000-0000.
  • Phone Type*

  • Emergency Contact

  • Format: (000) 000-0000.

  • Dental Insurance Information

  • Do you have dental insurance?*
  • Format: (000) 000-0000.
  • Policy Holder's Birth Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Policy Holder's Birth Date
     - -
  • Format: (000) 000-0000.

  • Dental History

  • How did you hear about our Practice?*
  • Has your child visited an orthodontist before?*
  • Has your child's tonsils or adenoids been removed?*
  • Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?*
  • Does your child you have any missing or extra permanent teeth?*
  • Has your child ever had an injury to (select all that apply)*
  • Does your child have speech problems?*
  • Does your child currently or has your child ever had any of the following habits?*

  • Medical History

  • Is your child currently being treated by a physician?*
  • Does your child have any allergies/sensitivities to medications or latex?*
  • Is your child currently taking any prescription or over-the-counter medications?*
  • Has puberty and/or menstruation begun?*
  • Is the patient pregnant?*
  • Check if your child has or have ever had any of the following*

  • Authorization

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
  • Date*
     - -

  • Authorization For Medical Records Release

    To Request Release Of Medical Information Please Complete And Sign This Form

  • I hereby voluntarily authorize the disclosure of information from my health record.

  • Date of Birth*
     - -


  • THE INFORMATION IS TO BE PROVIDED TO

  • Format: (000) 000-0000.

  • PLEASE SIGN BELOW TO COMPLETE THE FORM

  • This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Under HIPAA with a patient's written request, records must be provided within 30 days of a request.

  • Date*
     - -
  • Should be Empty: