Jacobus Orthodontics Child Health History Form

Jacobus Orthodontics Child Health History Form
Today's Date:*

MonthDayYear
Date
Gender:*

MaleFemale
Child's Name:*

First NameLast Name
Nickname:
SSN*
Grade*
School:*
Hobbies/Sports:*
Child's Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday:*

MonthDayYear
Date
Age:*
Who is accompanying your child today?
Name:*
Relation*
Do you have legal custody of this child?*

YesNo
Whom may we thank for referring you?
List brothers/sisters with age:
General Dentist:*
Last visit date:*

MonthDayYear
Date
Parents' Marital Status*

MarriedSingleDivorcedSeparatedWidowed
Parent's Information
Mother's Information:
Name:*

First NameLast Name
Birthdate:*

MonthDayYear
Date
Home number:*
Please enter a valid phone number.
Cell Number:*
Please enter a valid phone number.
Employer:*
Job Title:*
Work Number*
Please enter a valid phone number.
Ext:
How long?
Father's Information:
Name:*

First NameLast Name
Birthdate:*

MonthDayYear
Date
Home number:*
Please enter a valid phone number.
Cell Number:*
Please enter a valid phone number.
Employer:*
Job Title:*
Work Number*
Please enter a valid phone number.
Ext:
How long?
Person Responsible for Account
Name:*
Relation*
Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #:*
Please enter a valid phone number.
Cell #:*
Please enter a valid phone number.
Email Address:*
example@example.com
Employer:*
Work #:*
Please enter a valid phone number.
Ext.:
Primary Orthodontic Insurance
Orthodontic Coverage?*

YesNo
Insurance Co. Name:
Insurance Co. Phone #:
Please enter a valid phone number.
Policy/ID #:
Policy Owner's Name:
Relationship to Patient
Policy Owner's Birthdate:

MonthDayYear
Date
SSN:
Policy Owner's Employer:
Secondary Orthodontic Insurance
Orthodontic Coverage?*

YesNo
Insurance Co. Name:
Insurance Co. Phone #:
Please enter a valid phone number.
Policy/ID #:
Policy Owner's Name:
Relationship to Patient
Policy Owner's Birthdate:

MonthDayYear
Date
SSN:
Policy Owner's Employer:
What are the main concerns that you'd like orthodontic treatment to address?*
Has your child ever been evaluated or had orthodontic treatment before?*

YesNo
Have there been any injuries to the face, mouth, teeth, or chin?*

YesNo
List any musical instruments played:*
Have adenoids or tonsils been removed?*

YesNo
Has your child been informed of any missing or extra permanent teeth?*

YesNo
Has your child ever had any pain/tenderness in his/her jaw joint? (TMJ/TMD)*

YesNo
Child's Physician:*
Phone #:*
Please enter a valid phone number.
Date of last visit?*

MonthDayYear
Date
Is your child currently under the care of a physician?*

YesNo
Has puberty begun?*

YesNo
Has menstruation begun? (Females)*

YesNo
Please describe your child's current physical health:*

GoodFairBad
Please list all the drugs that your child is currently taking:*
Please list all the drugs/things that your child is allergic to:*
Has your child ever had any of the following medical conditions? Please check all that apply:*

Abnormal BleedingAllergies to any DrugsHandicaps/DisabilitiesHearing ImpairmentAllergic to Latex/MetalsAny OperationsKidney/Liver ProblemsRheumatic/Scarlet FeverCongenital Heart DefectConvulsions/EpilepsyDiabetesAllergic to PlasticHeart MurmurAny Hospital StaysHemophiliaHepatitisAsthmaHIV+/AIDSTuberculosis (TB)CancerNone
Please explain any medical conditions not listed above:
Does/ did your child have any of the following habits? Please check all that apply:*

Clenching/Grinding TeethNursing Bottle HandsThumbs/Finger SuckingNail BitingLip Sucking/BitingSpeech ProblemsMouth BreatherTongue ThrustNone
Neighbor or Relative not living with you:
Name:*
Phone:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.
Digital signature of parent or guardian:*

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Date:*

MonthDayYear
Date
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.
Digital signature of parent or guardian:*

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Date:*

MonthDayYear
Date
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
Digital signature of parent or guardian:*

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Date:*

MonthDayYear
Date
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
Office Use Only
I verbally reviewed the medical information with the parent/guardian and patient named herein.
Doctor's Comments:
Initials:
Date

MonthDayYear
Date
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

THE UNDERSIGNED ACKNOWLEDGES THE CURRENTLY EFFECTIVE NOTICE OF PRIVACY PRACTICES FOR DR. BRIAN B. JACOBUS, JR, D.D.S.,M.S.,P.A.
Date*

MonthDayYear
Date
A COPY OF THIS SIGNED, DATED ACKNOWLEDGMENT SHALL BE EFFECTIVE AS THE ORIGINAL
PLEASE SIGN YOUR NAME:*

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IF YOU ARE THE LEGAL REPRESENTATIVE OF THE PATIENT, PLEASE PRINT YOUR NAME IN DESCRIBED AUTHORITY
MOTHER:*
FATHER:*
LEGAL GUARDIAN: *
Should be Empty:

Jacobus Orthodontics Child Health History Form

Who is accompanying your child today?

Parent's Information

Mother's Information:

Father's Information:

Person Responsible for Account

Primary Orthodontic Insurance

Secondary Orthodontic Insurance

Neighbor or Relative not living with you:

Office Use Only

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES