Child New Patient Information

Child New Patient Information
Today's Date

MonthDayYear
Date
PATIENT INFORMATION
Patient Name

First NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
D.O.B.

MonthDayYear
Date
Gender*
School
Social Security Number
Physician*
Physician's Phone Number*
Please enter a valid phone number.
Whom may we thank for referring you to our office?*
Please list any family members who've been patients here:
PARENT 1 - PRIMARY CONTACT
Name
Marital Status
Address (if different than Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
D.O.B.

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
PARENT 2 INFORMATION
Name
Marital Status
Address (if different than Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
D.O.B.

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
INSURANCE INFORMATION
Primary Insurance
Policy Holder
D.O.B.

MonthDayYear
Date
Social Security Number
Dental Insurance Carrier
Insurance Carrier Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Group Number
Patient Number
Secondary Insurance
Policy Holder
D.O.B.

MonthDayYear
Date
Social Security Number
Dental Insurance Carrier
Insurance Carrier Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Group Number
Patient Number
MEDICAL HISTORY

Please check Yes or No if the patient has the following conditions:*

	Yes	No
Joint Swelling
Bone Disorders
Heart Trouble
Rheumatic Fever
Thyroid Problems
Diabetes
Hepatitis
Emotional Problems
Brain Injury
Kidney or Liver Involvement
AIDS/AIDS-Related Complex
Tuberculosis
Anemia
Asthma
Epilepsy
Prolonged Bleeding
Faintness or Dizziness
Tonsils Removed
Tonsilitis
Adenoids Removed
Sore Throats
Ear Aches

Other conditions or medical issues not listed above?

YesNo
Please describe any other medical issues:
Any injuries to the face, mouth, or teeth?

YesNo
Mouth-breathing when asleep, awake?

YesNo
More than average amount of tooth decay?

YesNo
Any missing permanent teeth?

YesNo
Any extra permanent teeth?

YesNo
Any teeth removed by extraction?

YesNo
Visits dentist regularly?

YesNo
Date of Last Visit

MonthDayYear
Date
General Dentist*
General Dentist Phone Number*
Has consulted an orthodontist before?

YesNo
Please describe:
Is this visit for a second opinion?

YesNo
Family history of under-bite (strong lower jaw)?

YesNo
History of thumb/finger sucking habit?

YesNo
Has history of speech therapy?

YesNo
Any difficulty swallowing or chewing?

YesNo
Any pain of clicking while opening mouth?

YesNo
Plays sports?

YesNo
Please list:
Uses mouth guards during sports?

YesNo
Drug allergies (penicillin, dental anesthetic, aspirin, etc.)?

YesNo
Please describe:
Other allergies (latex, gluten, peanuts)?

YesNo
Please describe:
Drugs or other medications now being taken?

YesNo
Please list medications:
Requires antibiotic pre-medication prior to dental procedures?

YesNo
Parent's Attitude About Orthodontic Care
ACKNOWLEDGMENT

In completing this form, I understand that the information I have provided is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in patient information or medical status.
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Date
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Child New Patient Information

PATIENT INFORMATION

PARENT 1 - PRIMARY CONTACT

PARENT 2 INFORMATION

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

MEDICAL HISTORY