Child New Patient Information

Tell Us About Your Child
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nickname
Child's Name

First NameLast Name
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
SS #
School
Grade
Hobbies/Sports/Interests
Child's Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is Accompanying Your Child Today?
Name

First NameLast Name
Relation to Patient
Do you have legal custody of this child?
Whom may we thank for referring you?
List other family members seen by us:
General Dentist
Date of last dental cleaning/visit:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Marital Status

Other
Parental Information
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer
How long have you been at your current job?
Job Title
SS #
DL #
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer
How long have you been at your current job?
Job Title
SS #
DL #
Orthodontic Insurance

Primary
Do you have orthodontic coverage?
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.Format: (000) 000-0000.
Group # (Plan, Local, or Policy #)
Policy Owner's Name

First NameLast Name
Relation to Patient
Policy Owner's Birthdate
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?
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.Format: (000) 000-0000.
Group # (Plan, Local, or Policy #)
Policy Owner's Name

First NameLast Name
Relation to Patient
Policy Owner's Birthdate
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)?
If Yes, when?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth, or chin?
List any musical instruments played:
Have the adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain/tenderness in their jaw joint (TMJ/TMD)?
Does your child brush their teeth daily?
Does your child floss their teeth daily?
Child's Physician
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is your child under the care of a physician?
Has puberty begun?
Girls: Has menstruation begun?
Please describe your child's current physical health?
Please list all drugs/medications that your child is currently taking:
Please list all drugs/materials that your child is allergic to:
Latex?
Metals/Nickels?
Plastics?

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

Rows	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?

Rows	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.Format: (000) 000-0000.
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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:

Tell Us About Your Child

Who is Accompanying Your Child Today?

Parental Information

Orthodontic Insurance

Orthodontic Insurance