Child New Patient Form

Child New Patient Form
How'd your hear about us?
Tell Us About Your Child
Today's Date*

MonthDayYear
Date
Nickname*
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*
School*
Grade*
Hobbies/Sports:*
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Information
Who is accompanying the child today?*

First NameLast Name
Relation to Patient*
Do you have legal custody of the child?*

YesNo
Whom may we thank for referring you?*
Other siblings to patient?*
General Dentist*
Date of last visit*

MonthDayYear
Date
Parent's Information
Who's responsible for the account?*
Marital Status*
FatherStep FatherGuardian
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is address different than child's?*

YesNo
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Employer*
Occupation*
If you have Orthodontic Insurance Coverage for the Child, please fill out the information below:
Policy Holder Name
Policy ID #
Insurance Company Name
Group # (Plan, Local, or Policy #)
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
MotherStep MotherGuardian
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Is address different than child's?

YesNo
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer
Occupation
If you have secondary orthodontic insurance coverage for the Child, please fill out the information below:
Do you have secondary orthodontic insurance coverage for the Child?

YesNo
Authorization
This office reserves the right to verify the credit status of potential patients and/or parents of potiential 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. 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. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. And I assign directly to the doctor all insurance benefits otherwise payabe to me. I further authorize the use of this signature or all my insurance submissions, whether manual or electronic.
Signature of Parent or Guardian*

Clear
Date

MonthDayYear
Date
Dental & Medical History
What are the main concerns that you would like orthodontics to accomplish?*
Has your child ever been evaluated or had treatment before?*

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

YesNo
Does the child require antibiotics before dental treatment?*

YesNo
Have the adenoids or tonsils been removed?*

YesNo
Does your child have any missing or extra permanent teeth?*

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

YesNo
Does the child brush their teeth daily?*

YesNo
Does the child floss their teeth daily?*

YesNo
Child's Physician*
Phone Number*
Please enter a valid phone number.
Date of Last Visit*

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

YesNo
Has puberty begun?*

YesNo
Has menstruation begun?*

YesNo
I would say the child's current physical health is...*
Please list all drugs that the child is currently taking:*
Aside from the items listed below, list all drugs/things your child is allergic to:*
Is the child allergic to Latex?*

YesNo
Is the child allergic to Nickel/Metals?*

YesNo
Is the child allergic to Plastic?*

YesNo

Has the child experienced the following medical problems?*

	Yes	No
Abnormal Bleeding
ADD/ADHD
AIDS/HIV+
Any Hospital Stays/Operations
Artificial Bones/Joints/Valves
Asthma
Autism
Cancer
Congenital Heart Defect
Convulsions
Covid-19
Diabetes
Epilepsy
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
Kidney Problems
Liver Problems
Mitral Valve Prolapse
Prosthetics
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease/Traits
Tuberculosis (TB)

Has the child ever taken any diet pills such as Phen-Fen? (Also known as Redux, Pondimin)*

YesNo
Has your child ever been prescribed Fosamax or any other bisphosphonate? If yes, when?

YesNo
Are the child's immunizations current?*

YesNo
Has the child been vaccinated for Covid-19?

YesNo
Anything you would like to discuss with the Doctor in private?*

YesNo
Please discuss any serious medical problems the child has had:*

Does/did the child experience any of the following?*

	Yes	No
Breast Fed
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb/Finger Sucking
Tongue Thrust
Used Pacifier

List any musical instruments played:*
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my chil's medical status. I authorize the dental staff to perform the necessary dental/orthodontic services my child may need.
Signature of Parent or Guardian*

Clear
Date

MonthDayYear
Date
Should be Empty:

Child New Patient Form

Tell Us About Your Child

General Information

Parent's Information

Authorization

Dental & Medical History