Keller + Wainwright Orthodontics

1301 SUNNYVALE SARATOGA RD, SUITE 2 SUNNYVALE, CA 94087 PHONE (408) 739-4224

GABRIELLE WAINWRIGHT, DDS, MSD REBECCA KELLER, DDS, MSD

Please fill out this form for your Child as completely as possible and email to us prior to your Initial Orthodontic Examination Appointment
ABOUT YOUR CHILD
Child's Name

First NameLast Name
Sex

MaleFemale
Todays Date

MonthDayYear
Date
He/She prefers to be called
Birthdate

MonthDayYear
Date
Age
School
Grade
Hobbies
Whom may we thank for referring your child to our office?
Other family members seen by Keller & Wainwright Orthodontics?
Is your child concerned about the appearance and health of his/her teeth?
Any missing or extra permanent teeth?
Has your child ever been diagnosed with sleep apnea?
Does your child want his/her teeth straightened?
Does you child want his/her teeth straightened?
PARENT'S INFORMATION
Parent(s) Marital Status

SingleMarriedDivorcedWidowedSeparated
If divorced or separated, who has primary custody?

MotherFatherOther
Father's Name

First NameLast Name
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at the above address?
Father's Employer
Years employed at current employer?
Father's Occupation
Father's Social Security Number
Father's Cell Phone Number
Please enter a valid phone number.
Father's Email
example@example.com
Father's Driver's License #
Father's Birthdate

MonthDayYear
Date
Mothers Name
Mother's Address (If different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years at Above Address?
Mother's Employer
Years Employed at Current Employer?
Mother's Occupation
Mother's Social Security #:
Mother's Cell Phone #
Please enter a valid phone number.
Mother's Email
example@example.com
Driver's License Number
Mother's Birthdate

MonthDayYear
Date
ORTHODONTIC INSURANCE
Is Orthodontic Coverage Available?*

YesNo
Name of Insured
Relationship to Patient
Insurance Company Name
Phone
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ins ID #
Is Secondary or Dual Coverage Available?

YesNo
Name of Insured
Relationship to Patient
Insurance Company Name
Insurance Phone
Insurance Company Address
Ins ID #
The information provided above may be used to obtain Insurance confirmation
MEDICAL INFORMATION
Physician's Name
Date of Last Medical Exam

MonthDayYear
Date
Address
Phone Number
Please enter a valid phone number.
If currently under a Physicians care for what reasons?
If taking any medications please list?
Is your child allergic to any medications? If so, please list:
Latex allergy?
Are any medications required prior to dental work?
Does your child have or has he/she ever had any of the following? Check if "Yes"

Heart DiseaseAbnormal Blood PressureRheumatic FeverAsthmaArthritisBleeding ProblemsAnemiaUlcersTuberculosis / Lung DiseaseVenereal DiseaseHepatitis / Liver ProblemsGlaucomaDiabetesEpilepsyFrequent HeadachesNervous DisordersCancer or LeukemiaRadiation TherapyH.I.V. PositiveCommunication disorderBone DisordersAllergiesSinus TroubleHay feverHerpesHearing DisabilityLearning DisorderGrowth Disorder
If yes, please explain:
Does your child's growth rate appear to be:

SlowAverageFast
Father's Height
Mother's Height
Is this child adopted?

YesNo
Female Patients Only: Has menstrual cycle started?

NoIf Yes, At What Age?
Male Patients Only: Has voiced changed?

YesIf Yes, At What Age?
DENTAL INFORMATION
Current Dentists Name
City
Date of Last Visit to the Dental Office

MonthDayYear
Date
Date of Last X-Rays

MonthDayYear
Date
Type?
Any current dental pain?
Has your child had or does he/she ever had any of the following: (Check if "Yes")

Teeth sensitive to hot, colds, sweets or pressureTraumatic injury to teeth or mouthPain or tenderness around ear, joint, or side of faceDifficulty in opening / closingDifficulty in chewingDifficulty in swallowingDifficulty in speakingClicking or popping of jaw jointClenching or grinding of teethPeriodontal treatmentTMJ / Splint treatmentUlcers / Cold SoresPain, swelling, or bleeding gumsLoosening of permanent teethThumb or finger suckingLip / Cheek bitingNail bitingTongue thrustMouth breathingNone of these apply
If yes, please explain:
Has your child ever had an upsetting experience in the dental office?
ORTHODONTIC INFORMATION
What is your primary concern about your child's teeth?
Do you have any concerns about orthodontic treatment?
Have you had other Orthodontic consultations / treatment?
Who was the orthodontist?
Please describe:
Have other family members had orthodontic treatment?
Who was the orthodontist?
Is there any additional information you would like us to know?
Signed

Clear
Date

MonthDayYear
Date
Should be Empty:

ABOUT YOUR CHILD

PARENT'S INFORMATION

ORTHODONTIC INSURANCE

MEDICAL INFORMATION

DENTAL INFORMATION

ORTHODONTIC INFORMATION