Zirbel Orthodontics Child Health History Form
Welcome to Zirbel Orthodontics!
Cassandra L. Zirbel, D.D.S., M.S.
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. Please fill out the following information to assist us with your child’s care and enhance customer service.
How did you hear about us?
Family member(s) are patients or had treatment at this office
Friends are patients or had treatment at this office
Referred by Dentist
Website
Mouthguard Clinic
Community Event
Other
If a family member or friend told you about us, please list their name and relation:
Tell us about your child
Child's Name:
*
First Name
Middle Name
Last Name
Child's Birthdate:
*
-
Month
-
Day
Year
Date
Age:
*
Gender:
*
School:
*
Grade:
*
Activities and interests:
List any siblings with age:
Child lives with:
Both Parents
Mother
Father
Other
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Dental History
General Dentist:
*
Has your child been seen by this dentist in the last year?
*
Yes
No
What is your dentist’s main concern with your child’s teeth?
What is your main concern with your child’s teeth?
Has your child been evaluated by another orthodontist?
*
Yes
No
Have x-rays been taken in the last 6 months? If yes, please list the date?
*
No
Yes
Has your child ever had any of the following:
Injury to the face, mouth, teeth or chin? If yes, please explain.
*
No
Yes
Jaw joint concerns? If yes, please explain.
*
No
Yes
Thumb or finger habit? If yes, is habit still present?
*
No
Yes
Speech Therapy? If yes, please explain:
*
No
Yes
Does your child brush his/her teeth daily?
*
Yes
No
Floss his/her teeth daily?
*
Yes
No
Have you been informed of any missing or extra permanent teeth?
*
Yes
No
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Medical History
Medications or supplements currently taking:
*
Does your child pre-medicate with antibiotics before dental procedures? if yes, please explain why.Is there any other dental health information you would like us to know? If yes, please explain.
*
No
Yes
Are immunizations up to date?
*
Yes
No
Please check if your child has or has had any of the following:
*
Allergies to Latex/Metals/Plastics (please list any other allergies below)
Arthritis
Asthma/Respiratory Condition
Autism
Birth Defects
Blood Disorders (Anemia/Low blood sugar)
Blood Pressure (High/Low)
Cancer/Leukemia
Congenital Heart Defect/Murmur
Cardiovascular Heart attack/Angina/Stroke
Diabetes
Digestive System Disorders
Disabilities or Handicaps
Eating Disorder
Endocrine
Eye Conditions
Epilepsy
Hearing Impairment
Hearing Aids
Headaches/Migraines
Hepatitis
HIV +/ AIDS
Immune System Disorders
Joint Replacement
Kidney/Liver Problems
Mental Health Condition - Anxiety/Depression (list any other conditions below)
Mouth-breathing/Snoring
Oral Ulcers
Osteoporosis
Pregnant (list due date below)
Seizures/Fainting
Sensory Conditions
Thyroid Condition
Tuberculosis (TB)
Tonsils/Adenoids Removed
None of the Above
Any additional allergies:
Any mental health conditions not listed above:
Due date, if pregnant:
-
Month
-
Day
Year
Date
Is your child currently under the care of a physician for any other health information we should know about? If yes, please explain.
*
No
Yes
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Responsible Party Information
Please complete a section for each person sharing responsibility for your child. This request is for accuracy with insurance, communication and HIPAA.
Full Name:
*
First Name
Middle Name
Last Name
Birthdate:
*
-
Month
-
Day
Year
Date
Relation
*
Mother
Step Mother
Father
Step Father
Guardian
Marital Status:
*
Married
Single
Divorced
Separated
Widowed
Cell #:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate #:
Please enter a valid phone number.
Format: (000) 000-0000.
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Yes
No
Preferred Contact Method:
*
Voice Message
Email
Can we leave a detailed message?
*
Yes
No
Email:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this person a dental insurance policy holder? If yes, please list the Dental Insurance Company.
*
No
Yes
Employer:
*
Occupation
*
Subscriber ID:
Group ID:
Address of Dental Insurance Company
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse or Additional Responsible Party Name:
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Relation
Mother
Step Mother
Father
Step Father
Guardian
Marital Status:
Married
Single
Divorced
Separated
Widowed
Cell #:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate #:
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method:
Voice Message
Email
Can we leave a detailed message?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation
Is this person a dental insurance policy holder? If yes, please list the Dental Insurance Company.
No
Yes
Subscriber ID:
Group ID:
Address of Dental Insurance Company
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload a photo of the insurance card.
Browse Files
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Choose a file
Cancel
of
Please upload a photo of the front of your insurance card.
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Choose a file
Cancel
of
Please upload a photo of the back of your insurance card.
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Choose a file
Cancel
of
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Secondary Insurance
Do you have secondary insurance? If yes, please answer the following questions. If you do not, please skip the rest of this section.
*
Yes
No
Are you the dental insurance policy holder? If not, please list the name of the holder.
Yes
No
Birthdate of Insurance Policy Holder:
-
Month
-
Day
Year
Date
Dental Insurance Company
Policy Holder's Employer Name
Address of Dental Insurance Company
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber ID
Group ID
Please upload a photo of your insurance card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Additional Responsible Party Information for Multiple Households
Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Relation
Mother
Step Mother
Father
Step Father
Guardian
Marital Status
Married
Single
Divorced
Separated
Widowed
Cell #:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate #
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method:
Voice Message
Email
Can we leave a detailed message?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this person a dental insurance policy holder? If yes, please list the Dental Insurance Company.
No
Yes
Spouse or Additional Responsible Party Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Relation
Mother
Step Mother
Father
Step Father
Guardian
Marital Status
Married
Single
Divorced
Separated
Widowed
Cell #:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate #
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method:
Voice Message
Email
Can we leave a detailed message?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation
Is this person a dental insurance policy holder? If yes, please list the Dental Insurance Company.
No
Yes
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Person Responsible for Account
*
Both Parents
Mother
Father
Step Mother
Step Father
Guardian
Other
Authorization and Signature On File
By Signing below, I authorize this office and it’s employees to use this form’s information to act as my agent to assist with insurance reimbursement and have insurance payments made directly to this office. I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes.
Signature of Parent or Guardian:
*
Today's Date
*
-
Month
-
Day
Year
Date
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDA and ADA
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