Child Patient Information
Name
First Name
Middle Name
Last Name
Nickname
Age
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
DOB
-
Month
-
Day
Year
Date
SS #
Patient's General Dentist
Last Visited
Email for confirmation
example@example.com
How did you hear about our office?
Are there other family members who already see us? If so, who?
Responsible Party Information
Responsible Party #1
Relationship to Patient (Mother, Father, etc)
Name
First Name
Middle Name
Last Name
SS #
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years at current address
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
Occupation
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Years of employment
Responsible Party #2
Relationship to Patient (Mother, Father, etc)
Name
First Name
Middle Name
Last Name
SS #
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years at current address
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
Occupation
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Years of employment
Insuarance
Do you have orthodontic insurance?
Yes
No
PLEASE HAVE YOUR CARD AVAILABLE FOR FRONT DESK CLERK
Primary Insurance Company
Policy Holder's Name
First Name
Last Name
Member/Contract/Policy ID #
Group #
DOB
-
Month
-
Day
Year
Date
Policy Holder's SS #
Relationship to Patient
General Information
Patient's School
Siblings (please include ages)
Patient's hobbies
Medical History
Primary concern for orthodontic treatment
Primary Medical Physician
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Last visit
-
Month
-
Day
Year
Date
Is the patient in overall good health?
Has puberty/menstruation began?
List any known medical conditions
List any medications now being taken, give reason
Are you allergic to any of the following?
Aspirin
Latex
Nickel
Penicillin
Any other metals/plastics
Other
Has a doctor/dentist ever told you to pre-medicate with antibiotics before dental treatment?
Dental History
Has the patient's tonsils and/or adenoids been removed?
Yes
No
Has the patient had an orthodontist evaluation/treatment before?
Yes
No
Has the patient experienced jaw joint pain/discomfort?
Yes
No
Has the patient ever had an injury to teeth/mouth/chin?
Yes
No
Has the patient ever been informed of missing or extra permanent teeth?
Yes
No
Does anyone in the patient's family have a similar dental condition?
Yes
No
Does/Has the patient's you ever had any of the following habits?
Lip biting/sucking
Clenching/grinding teeth
Mouth Breather
Nail Biting
Tongue thrusting
Thumb/finger sucking
Speech problems
Other
Responsible Party Signature
Date
-
Month
-
Day
Year
Date
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