New Patient Child Form
Patient Name
First Name
Last Name
Preferred Name
Age
Sex
Please Select
Male
Female
DOB
-
Month
-
Day
Year
Date
School
Grade
Hobbies/Interests
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist Name
Last Visit
-
Month
-
Day
Year
Date
Whom can we thank for referring you to our office?
Father's Name
Social Security #
DOB
-
Month
-
Day
Year
Date
Employer
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Name
Social Security #
DOB
-
Month
-
Day
Year
Date
Employer
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person Responsible for Account
Relationship to Patient
Where did you see us?
Please Select
Internet
Yellow Pages
Front Sign
Flyer
Other
Do you have orthodontic insurance?
Yes
No
Primary Subscriber Name
DOB
-
Month
-
Day
Year
Date
Subscriber's Social Security #
Employer
Name of Insurance
Insurance Phone
Please enter a valid phone number.
Format: (000) 000-0000.
For Secondary Coverage Only:
Secondary Subscriber Name
DOB
-
Month
-
Day
Year
Date
Subscriber's Social Security #
Employer
Name of Insurance
Insurance Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Please check the following as they apply:
Jaw Joint Problems
Heart Problems
Kidney Problems
Liver Disease
High Blood Pressure
Pregnancy
Congenital Heart Conditions
Head or Facial Injuries
Ear Infections
Allergies
Diabetes
Bleeding Disorder
Asthma
Epilepsy
Speech Problems
Endocrine Disorder
Nervous Disorder
Rheumatic Fever
Artificial Joints
Other
If Other, please describe:
Is the patient currently under the care of a physician?
Yes
No
If Yes, please explain:
Dental History
Has the patient ever had any injuries to the face, mouth, or teeth?
Yes
No
Has the patient ever sucked a thumb or finger?
Yes
No
If Yes, until what age?
If Yes, please explain:
Has the patient received previous orthodontic care?
Yes
No
If Yes, by whom?
What part of your child's orthodontic problem concerns you the most?
Is there any additional information that you feel we need in order to make this a more enjoyable experience for your child?
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: