Child Patient Form
Patient Information
Patient's Name
First Name
Last Name
Gender
Please Select
Male
Female
Other
Age
Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Hobbies
School
Referred by:
Dentist's Name
Who their dentist is?
When was their last dental cleaning?
-
Month
-
Day
Year
Date
Who referred them to our office?
Responsible Party Information
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Work/Employment
Patient Orthodontic Insurance Information
Are you covered by an Orthodontic Insurance Plan?
Yes
No
Subscriber Name
First Name
Last Name
Social Security Number
Insurance Company
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber ID #
Group #
Patient Health Information
Name of Medical Doctor
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is the patient in good health?
Yes
No
Does the patient have any history of major illness?
Yes
No
Is the patient under the care of a physician?
Yes
No
If so, please explain:
Check any of the following which you have had or have at the present:
Diabetes
Pneumonia/TB
Heart Trouble
Rheumatic Fever
Bone Disorder
HIV/AIDS
Anemia
Asthma
Epilepsy
Ulcers
Blood Transfusion
Allergies/Hives
Kidney/Liver Disease
High Blood Pressure
Hepatitis/Jaundice
Sinus Problems
Blood Disorder
Endocrine Problem
Prolonged Bleeding
Fainting/Dizziness
Respiratory Problem
Nervous Disorder
Venereal Disease
Congenital Heart Lesion
Stomach/Intestinal Problem
Does the patient have any disease, condition, or health problem not listed above?
Yes
No
Please list any drug/medications the patient is currently taking:
Please list any allergies or drug sensitivities the patient may have:
Has the patient ever had any X-ray treatment (other than diagnostic)?
Yes
No
Patient's Approximate Height
Patient's Approximate Weight
Has the patient reached puberty?
Yes
No
If the patient is a girl, has she started menstruation yet?
Yes
No
If the patient is a boy, has his voice begun to change?
Yes
No
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Has the patient ever had a habit of sucking their thumb/fingers?
Yes
No
Does the patient grind/clench their teeth or jaw during the day or at night?
Yes
No
Is the patient a mouth-breather while they are awake?
Yes
No
Is the patient a mouth-breather while they are sleeping?
Yes
No
Has the patient been informed of any missing or extra permanent teeth?
Yes
No
Has an orthodontic professional previously been consulted?
Yes
No
Has either parent had orthodontic treatment?
Yes
No
Please check the reason for today's visit:
Crowding
Spacing
Missing Teeth
Overbite
Timing for Treatment
Other
Parent's Signature
Date
-
Month
-
Day
Year
Date
Practice Witness
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: