Child New Patient Information

Child New Patient Information
Tell Us About Your Child
Date

MonthDayYear
Date
Nickname
Child's Name

First NameLast Name
MaleFemale
Birthdate

MonthDayYear
Date
Age
SS #
School
Grade
Hobbies/Sports/Interests
Child's Home Phone
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Who is Accompanying Your Child Today?
Name

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

YesNo
Whom may we thank for referring you?
List other family members seen by us:
General Dentist
Date of last dental cleaning/visit:

MonthDayYear
Date
Parent's Marital Status

SingleMarriedSeparatedDivorcedWidowed
Parental Information
MotherStep-MotherGuardian
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Employer
How long have you been at your current job?
Job Title
SS #
DL #
FatherStep-FatherGuardian
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Employer
How long have you been at your current job?
Job Title
SS #
DL #
Orthodontic Insurance

Primary
Do you have orthodontic coverage?

YesNo
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Group # (Plan, Local, or Policy #)
Policy Owner's Name

First NameLast Name
Relation to Patient
Policy Owner's Birthdate

MonthDayYear
Date
Policy Owner's ID #
Policy Owner's Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Orthodontic Insurance

Secondary
Do you have orthodontic coverage?

YesNo
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Group # (Plan, Local, or Policy #)
Policy Owner's Name

First NameLast Name
Relation to Patient
Policy Owner's Birthdate

MonthDayYear
Date
Policy Owner's ID #
Policy Owner's Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What would you like orthodontics to accomplish?
Has your child ever taken Phen-Fen (Redux or Pondimin)?

YesNo
If Yes, when?
Has your child ever been evaluated or had orthodontic treatment before?

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

YesNo
List any musical instruments played:
Have the adenoids or tonsils been removed?

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

YesNo
Has your child ever had any pain/tenderness in their jaw joint (TMJ/TMD)?

YesNo
Does your child brush their teeth daily?

YesNo
Does your child floss their teeth daily?

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

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

YesNo
Has puberty begun?

YesNo
Girls: Has menstruation begun?

YesNo
Please describe your child's current physical health?

GoodFairPoor
Please list all drugs/medications that your child is currently taking:
Please list all drugs/materials that your child is allergic to:
Latex?

YesNo
Metals/Nickels?

YesNo
Plastics?

YesNo

Has your child ever had any of the following medical problems?*

	Yes	No
Abnormal Bleeding
ADD/ADHD
Allergies to Any Drugs
Allergic to Latex/Metals
Allergic to Plastic
Any Hospital Stays
Any Operations
Artificial Bones/Joints
Artificial Valves
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+/AIDS
Kidney/Liver Problems
Lupus
Rheumatic/Scarlet Fever
Tuberculosis (TB)

Please discuss and medical problems that your child has that were not noted above:

Has your child ever experienced any of the following?*

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

Name of Neighbor/Relative Not Living With You

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that the information I have given today 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 child's medical status. I authorize the dental staff to perform any necessary dental services that my child may need.
Signature of Parent or Guardian

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Date

MonthDayYear
Date
This office reserves the right to verify the credit status of potential patients and/or parents of patients 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.
Signature of Parent or Guardian

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Date

MonthDayYear
Date
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 payment of the group insurance benefits directly to this office.
Signature of Parent or Guardian

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Date

MonthDayYear
Date
The Parent or Guardian who accompanies the child is responsible for payment.

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.
Should be Empty:

Child New Patient Information

Tell Us About Your Child

Who is Accompanying Your Child Today?

Parental Information

Orthodontic Insurance

Orthodontic Insurance