Child Registration Form

Child Registration Form
Patient Name

First NameMILast Name
Gender
SS #
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Phone Type
OK to leave a message?
Email
example@example.com
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Parent / Guardian Information

Parent 1
Name

First NameLast Name
Marital Status
Relation to Child

Other
SS #
Birth Date

MonthDayYear
Date
Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Phone Type
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Type
Employer's Name
Occupation
Parent 2
Name

First NameLast Name
Marital Status
Relation to Child

Other
SS #
Birth Date

MonthDayYear
Date
Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Phone Type
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Type
Employer's Name
Occupation
Emergency Contact Information
Emergency Contact Name (other than parent)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) you allow us to release appointment or medically-related information regarding your child to
Relation(s) to Child
Insurance Information

Primary Insurance
Primary Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group #
Policy #
Member ID #
Co-pay (if known)
Deductible (if known)
Policy Holder's Name

First NameLast Name
Relation to Patient
Policy Holder's SS #
Policy Holder's DOB

MonthDayYear
Date
Employer
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance
Secondary Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group #
Policy #
Member ID #
Co-pay (if known)
Deductible (if known)
Policy Holder's Name

First NameLast Name
Relation to Patient
Policy Holder's SS #
Policy Holder's DOB

MonthDayYear
Date
Employer
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dental History
General Dentist
Last Visit
How did you hear about our practice?

Other
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to correct?
Has your child visited an orthodontist before?
If yes, when?
Reason
Name
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply)
Does your child have speech problems?
If so, explain
Does your child currently or has your child ever had any of the following habits (check all that apply)
Medical History
Is your child currently being treated by a physician?
Reason
Physician
Last Visit

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is your child currently taking any prescription or over-the-counter medications?
If yes, please list with the dosage
Has puberty and/or menstruation begun?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
If yes, give approximate dates:
Check if your child has or has ever had any of the following:
Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.
Signature
Date

MonthDayYear
Date
Should be Empty:

Child Registration Form

Parent / Guardian Information

Emergency Contact Information

Insurance Information

Dental History

Medical History