New Patient Child Form

New Patient Child Form
Patient Name

First NameLast Name
Preferred Name
Age
Sex
DOB

MonthDayYear
Date
School
Grade
Hobbies/Interests
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Dentist Name
Last Visit

MonthDayYear
Date
Whom can we thank for referring you to our office?
Father's Name
Social Security #
DOB

MonthDayYear
Date
Employer
Phone Number
Please enter a valid phone number.
Mother's Name
Social Security #
DOB

MonthDayYear
Date
Employer
Phone Number
Please enter a valid phone number.
Person Responsible for Account
Relationship to Patient
Where did you see us?
Do you have orthodontic insurance?

YesNo
Primary Subscriber Name
DOB

MonthDayYear
Date
Subscriber's Social Security #
Employer
Name of Insurance
Insurance Phone
Please enter a valid phone number.
For Secondary Coverage Only:
Secondary Subscriber Name
DOB

MonthDayYear
Date
Subscriber's Social Security #
Employer
Name of Insurance
Insurance Phone
Please enter a valid phone number.
Please check the following as they apply:

Jaw Joint ProblemsHeart ProblemsKidney ProblemsLiver DiseaseHigh Blood PressurePregnancyCongenital Heart ConditionsHead or Facial InjuriesEar InfectionsAllergiesDiabetesBleeding DisorderAsthmaEpilepsySpeech ProblemsEndocrine DisorderNervous DisorderRheumatic FeverArtificial JointsOther
If Other, please describe:
Is the patient currently under the care of a physician?

YesNo
If Yes, please explain:
Dental History
Has the patient ever had any injuries to the face, mouth, or teeth?

YesNo
Has the patient ever sucked a thumb or finger?

YesNo
If Yes, until what age?
If Yes, please explain:
Has the patient received previous orthodontic care?

YesNo
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

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

New Patient Child Form

Dental History