child new patient form

Mogavero Orthodontics Child New Patient Form

Information must be filled out completely
Name*

First NameLast Name
School
Date of Birth

MonthDayYear
Date
Grade
Special Interests, Sports or Hobbies*
Siblings Names and Date of Birth
General Dentist
Date of Last Visit

MonthDayYear
Date
Whom may we thank you for referring you to our office?
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Custodial Parent Information
Relationship*

MotherStep MotherGuardianFather
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Work Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Employer Name
Additional Parent Information
Relationship to Patient
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Work Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Employer Name
Primary Orthodontic Insurance
Policy Holder's Name
Birthdate

MonthDayYear
Date
ID #
Employer Name
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #

Area CodePhone Number
Group / Plan #
Secondary Orthodontic Insurance
Policy Holder's Name
Orthodontic Coverage

YesNo
Relationship to Patient
Birthdate

MonthDayYear
Date
ID #
Insurance Company
Employer Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #

Area CodePhone Number
Group / Plan #
What are the main concerns you would like orthodontics to address?
Parent
Child
Dentist
Has your child ever had or been evaluated for orthodontic treatment before?
Have there been any injuries to the face, teeth, jaw, mouth or chin? Please Explain
Have adenoids or tonsils been removed?

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

YesNo
If yes, which ones?
Has your child ever had any pain or tenderness in the jaw joint? (TMJ, TMD)?

YesNo
Does your child brush his/her teeth daily?

YesNo
Does your child floss his/her teeth daily?

YesNo
Child's Physician
Phone Number

Area CodePhone Number
Date of Last Visit

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

YesNo
Please describe your child's physical health

ExcellentGoodFairPoor
Please list all medications that you child is currently taking and for what conditions
Please list any medications that your child is currently allergic to.

Has your child ever had any of the following medical issues?

	Yes	No
Abnormal Bleeding
Allergies to any drugs, latex/metals or plastics
Any Hospital stays
Any Operations
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatits
HIV + / AIDS
Kidney/Liver Problems
Rheumatic/Scarlet Fever
Tuberculosis (TB)
History of Endocardinitis
Artificial valves including prosthetic material and devices
Heart Transplant

Do you/your child require antibiotic prophylaxis prior to your dental visit*

YesNo

Does your Child have any of the following habits?

	Yes	No
Clenching/Grinding Teeth
Nurse Bottle Habits
Lip Sucking/Biting
Speech Problems
Mouth Breather
Thumb/Finger Sucking
Nail Biting
Tongue Thrust

If you have any other medical issues not listed above, please describe*
Please list an emergency contact not living with you
Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agree to Terms

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 the patient's medical status. I also authorize Mogavero Orthodontics staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used for professional consultations and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.

I agree to Terms of Service and Privacy Policy provided by Mogavero Orthodontics. By providing my phone number, I agree to receive text messages from Mogavero Orthodontics. I understand I can SMS opt-out at any time by responding "Stop."
I Agree to the above terms and conditions*

Yes
Should be Empty:

Mogavero Orthodontics Child New Patient Form