Child New Patient Form

Child New Patient Form
Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nickname
Birthdate

MonthDayYear
Date
Social Security #
School
Sports/Hobbies
Parent/Guardian Name

First NameLast Name
Whom may we thank for referring you to our office?
Responsible Party Information
Name

First NameLast Name
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Birthdate

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
Number of Years Employed
Spouse's Name

First NameLast Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Social Security #
Birthdate

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Dental Insurance Information
Insured's Name

First NameLast Name
Social Security #
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do you have dual coverage?

YesNo
Insured's Name

First NameLast Name
Social Security #
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Information
Name of nearest relative not living with you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
I understand that, where appropriate, credit bureau reports may be obtained.
Signature

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Date

MonthDayYear
Date
Medical History
Physician
Date of Last Visit

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Is the patient taking any medication?

YesNo
Is the patient allergic to any medication?

YesNo
Does the patient have a history of a major illness?

YesNo
Has the patient had any operations?

YesNo
Has the patient ever been involved in a serious accident?

YesNo
Have you seen a physician in the last 12 months?

YesNo
If you selected Yes to any of the above questions, please provide details:
For Female Patients Only
Are you pregnant?

YesNo
Has menstruation started?

YesNo
Select any of the medical conditions below that you have had or currently have:

Abnormal Bleeding/HemophiliaAnemiaArthritisAsthma or HayfeverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver ProblemsHerpesHigh Blood PressureHIV/AIDSKidney ProblemsNervous DisordersPneumoniaProlonged BleedingRadiation/ChemotherapyRheumatic FeverTuberculosisTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns the patient most about their teeth?
Is the patient presently in any dental pain?

YesNo
Has the patient ever experienced any favorable reaction to dentistry?

YesNo
Has the patient ever lost or chipped any teeth?

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

YesNo
Is any part of the patient's mouth sensitive to pressure?

YesNo
If Yes, where?
Is any part of the patient's mouth sensitive to temperature?

YesNo
If Yes, where?
Does the patient's gums bleed when you brush?

YesNo
Does the patient have any type of thumb or tongue habit?

YesNo
Is the patient a mouth breather?

YesNo
Has the patient ever seen an orthodontist?

YesNo
If Yes, who and when?
What is the patient's attitude toward receiving orthodontic treatment?
Has anyone in the patient's family received orthodontic treatment?

YesNo
How did they feel about the result?
Do the patient's teeth or jaws ever feel uncomfortable when they awake in the morning?

YesNo
Is the patient aware of clenching their teeth during the day?

YesNo
Has the patient ever been told that they grind your teeth?

YesNo
Does the patient have "tension" headaches?

YesNo
Has the patient ever experienced chronic ringing in their ears?

YesNo
Does the patient need extra help with instructions?

YesNo
Is the patient sensitive or self-conscious about their teeth?

YesNo
Height of Parents
Mom Height
Dad Height
Are you aware that some appointments will be during work hours?

YesNo
Benefits
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are intricate body parts and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Faulkner to perform a complete orthodontic evaluation.
Signature

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Date

MonthDayYear
Date
Should be Empty:

Child New Patient Form

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

For Female Patients Only

Dental History

Benefits