Welcome to the Orthodontist

Child Patient Form
We would like to welcome you and your child to our office. Our goal is to make everyone's visit pleasant, stress-free and educational. We pride ourselves in creating beautiful smiles that lasts a lifetime. We look forward to seeing you in the office.
Child's Name*

FirstLast
Name your child prefers to be called?*
Child's Birthdate*

MonthDayYear
Date
Email*
School:*
Grade
Special Interests, Hobbies/Sports:
Does the patient have siblings?*
Siblings Names and ages*
General Dentist:*
Last Visit Date:*
Whom may we Thank for referring you?*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #
Cell Phone #*
Custodial Parent Information

Patient Information
Relationship*
Marital Status?*
Name of Parent/Guardian*

First NameLast Name
Parent/Guardian Birthdate*

MonthDayYear
Date
Work Phone #
Cell #*
Home Phone #
Employer*
Is there another parent involved in the child's life?*
Additional Parent Information
Name

First NameLast Name
Parent/Guardian Birthdate:
Cell #
Home Phone #
Work Phone #
Address (If different)
Employer
Primary Orthodontic Insurance
Do you currently have dental insurance that covers orthodontics*

YesNo
Policy Holder's Name

First NameLast Name
Policy Owner's Birthdate

MonthDayYear
Date
Employer Name
Insurance Company Name
Insurance Company Phone #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Member ID
Relationship to Patient
Secondary Insurance
Policy Owner's Name
Policy's Owner's Birthdate

MonthDayYear
Date
Employer Name
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #
Group # (Plan, Local or Policy #)
Member ID
Relationship to Patient
What are the main concerns you or your child's dentist would like orthodontics to address?
Explain*
Has your child ever been evaluated or had orthodontic treatment before?*

YesNo
Have there been any injuries to the face, teeth, jaw, mouth, or chin? Please explain:*
Have adenoids or tonsils been removed?*

YesNo
Has your child been informed of any missing or extra permanent teeth?*

YesNo
If yes, which ones?
Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)?*

YesNo
Does your child brush his/her teeth daily?*

YesNo
Does your child floss his/her teeth daily?*

YesNo

Does the patient have any of the following habits?*

	Yes	No
Clenching/Griding Teeth
Nurse Bottle Habits
Lip Sucking/Biting
Thumb / Finger Sucking
Mouth Breather
Nail Biting
Speech Problems
Tongue Thrust

Medical History
Child's Physician*
Phone Number*
Date of Last Visit*

MonthDayYear
Date
Is your child currently under the care of a physician?*

YesNo
Please describe your child's physical health*

ExcellentGoodFairPoor
Please list all medications that your child is currently taking and for what conditions:
Please list any medications that your child is currently allergic to:
If your child is a girl, has menstruation begun?

YesNo
If Yes, how long ago?

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

	Yes	No
Abnormal Bleeding
Allergies to any drugs
Allergy to latex/metals
Allergy to plastic
Any Operations
Asthma
Cancer
Congenital Heart Defect
Diabetes
Epilepsy/Convulsions
Handicaps/Disabilites
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
Kidney / Liver Problems
Rheumatic Fever
Tuberculosis (TB)
Any Hospital Stays
HIV +/AIDS

Emergency Contact

Please list an emergency contact not living with you
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Acknowledgement of Office Policies*

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the staff to perform the necessary orthodontic services I/my child may need.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 services of one or more credit reporting agencies.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 understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Child Patient Form

Custodial Parent Information

Additional Parent Information

Primary Orthodontic Insurance

Secondary Insurance

What are the main concerns you or your child's dentist would like orthodontics to address?

Medical History

Emergency Contact