Child Patient Information
Patient's Name
What do you prefer to be called?
Patient Gender
Please Select
Male
Female
Other
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Company
Do you wish to receive appointment reminders?
Text
Email
Both
Just like phone calls and voicemails, texting may not always be 100% secure depending on the mobile service you use. Knowing that, would you like us to communicate with you via text?
Yes
No
Who is your general dentist?
Approximate date of last appointment?
-
Month
-
Day
Year
Date
Whom may we thank for referring you to Champlain Orthodontics?
School
Homeschooled
Hobbies/Interests
Immediate family treated by COA
Siblings & ages
Responsible Party
Parent/Guardian/Domestic Partner
Name
Relationship to patient?
Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian/Domestic Partner
Name
Relationship to patient?
Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Dental Insurance Information
Primary Dental Insurance
Dr. Dynasaur/Green Mountain Care
Children with Special Health Needs
Subscriber's Name
Subscriber's Employer
Insurance Company
ID/Subscriber #
Subscriber date of birth
-
Month
-
Day
Year
Date
SSN
Relationship to patient
Has Secondary Dental Insurance
Subscriber's Name
Subscriber's Employer
Insurance Company
ID/Subscriber #
Subscriber date of birth
-
Month
-
Day
Year
Date
SSN
Relationship to patient
Medical History
Primary Care Physician
Last Visit
-
Month
-
Day
Year
Date
Are you currently under the care of a physician? If yes, explain
Have you ever been evaluated for orthodontic treatment?
What are your orthodontic concerns?
Has the patient tonsils or adenoids been removed?
Yes
No
Has the patient experienced jaw joint pain/discomfort? (TMJ/TMD)?
Yes
No
Does the patient have missing or extra permanent teeth?
Yes
No
Has the patient had an injury to?
Chin
Teeth
Mouth
Does the patient have a history of eating disorders?
Yes
No
Does/has the patient had any of the following habits?
Clenching Teeth
Lip Sucking/Biting
Nail Biting
Prolonged Bottle/Pacifier
Grinding Teeth
Mouth Breathing
Tongue Thrusting
Thumb/Finger Sucking
Does the patient have speech problems? If yes, please explain:
Is the child allergic to any of the following?
Aspirin
Codeine
Tetracycline
Metals/Plastics
Erythromycin
Penicillin
Latex
Other
No Known Allergies
Do your gums bleed?
Yes
No
Do you like your smile?
Yes
No
List all drugs the patient is currently taking:
List any serious medical conditions:
Emergency Contact
Name
Relationship to patient
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held to the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.
Date
-
Month
-
Day
Year
Date
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