• Child Patient Information Form

    Child Patient Information Form

  • Sex*
  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does this person have legal custody of you?*
  • Format: (000) 000-0000.
  • Date Of Last Visit*
     - -
  • Format: (000) 000-0000.
  • Date Of Last Visit*
     - -

  • Guardian One Information

  • I am the:*
  • Birthday*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the patient live with you full time?*

  • Guardian Two Information

  • I am the:*
  • Birthday*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the patient live with you full time?*

  • Person Responsible Account

  • Birthday*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Orthodontic Insurance

  • Do you have orthodontic insurance?*
  • Format: (000) 000-0000.
  • Policy Owner's Date of Birth
     - -

  • Medical History

  • Have you ever been evaluated or had orthodontic treatment before?*
  • Have you been informed of any missing or extra permanent teeth?*
  • Do you still have your wisdom teeth?*
  • Have you experienced problems with previous dental work?*
  • Have you ever had any pain / tenderness in your jaw joint (TMJ/TMD)?*
  • Has your jaw ever clicked, popped or locked?*
  • Do you brush your teeth daily?*
  • Do you floss your teeth daily?*
  • Do your gums bleed?*
  • Have there been any injuries to your face, mouth, teeth or chin?*
  • Do you currently feel healthy?*
  • Do you need to be premedicated before dental work?*
  • Are you taking fluoride supplements?*
  • Have adenoids or tonsils been removed?*
  • Are Immunizations current?*
  • Boys: Has puberty begun?
  • Boys: Has your voice changed?
  • Girls: Has puberty begun?
  • Girls: Do you take birth control pills?
  • Girls: Are you pregnant?
  • Are you Allergic to any of the following?*
  • Do you now have or have you had any of the following habits?*
  • Do you now have or have you had any of the following?*

  • Signature

  • Our office is committed to meeting or exceeding the standards of infection control
    mandated by OSHA, the CDC and the ADA.

    We reserve the right to verify the credit status prior to extending credit for treatment.

    I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.

  • Date*
     - -
  • Should be Empty: