Clone of Bhatia Orthodontics - Child Patient Form

Child Patient Information Form
Speed up your visit by completing your registration and health history forms online ahead of time! Just spend a few moments filling out this private form and select "submit". Your details will be securely encrypted and sent directly to our office. Everything will be ready for us to review when you arrive for your first appointment.
Child's Name*

First NameMiddle NameLast Name
I prefer to be called (Nickname):
Child's Birthdate*

MonthDayYear
Date
Child's Sex:*
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.
Phone Type*
School:
Grade
Special Interests, Hobbies/Sports:
Have we seen any other family members?*
Whom may we thank for referring you to our office?*
Custodial Parent Information
Relationship to Child*
Marital Status*
Name of Parent/Guardian*

First NameLast Name
Birthdate of Parent/Guardian*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone numberFormat: (000) 000-0000.
Phone Type*
Is there another parent involved in the child's life?
Additional Parent Information
Relationship to Child*
Marital Status*
Name of Parent/Guardian*

First NameLast Name
Birthdate of Parent/Guardian

MonthDayYear
Date
Email
example@example.com
Address (if different from custodial parent)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone numberFormat: (000) 000-0000.
Phone Type*
Primary Dental Insurance Information
Do you currently have dental insurance? If so, may we verify your benefits for your child?*
Policy Holder's Name*

First NameLast Name
Policy Owner's Birthdate*

MonthDayYear
Date
Policy Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Policy Holder's Relationship to Patient*
Insurance Card Image Upload

Cancelof
Insurance Company Name
Insurance Company Phone #
Format: (000) 000-0000.
Member ID
Group # (Plan, Local or Policy #)
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance?
Secondary Insurance
Policy Holder's Name*

First NameLast Name
Policy Owner's Birthdate*

MonthDayYear
Date
Policy Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Policy Holder's Relationship to Patient*
Insurance Card Image Upload

Cancelof
Insurance Company Name
Insurance Company Phone #
Format: (000) 000-0000.
Member ID
Group # (Plan, Local or Policy #)
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental History
What are the main concerns you or your child's dentist would like orthodontics to address?*
General Dentist*
Date of Last Visit*

MonthDayYear
Date
Has your child ever seen an Orthodontist?*
If yes, Who?
When?
Have there been any injuries to the face, teeth, jaw, mouth, or chin? Please explain:*
Have adenoids or tonsils been removed?*
Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)?*
Has your child been informed of any missing or extra permanent teeth?*
Does your child brush his/her teeth daily?*
Does your child floss his/her teeth daily?*

Does your child have any of the following habits?*

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

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect treatment you receive from our office. This information is kept strictly confidential.
Child's Physician*
Date of Last Visit*

MonthDayYear
Date
Is your child currently under the care of a physician for any specific condition?*
If yes, please explain:
Please list all medications that your child is currently taking and for what conditions:*
Enter "n/a" if your child is not currently taking any medications
Please list any allergies your child currently has:
Enter "n/a" if your child does not have any allergies
If your child is a girl, has menstruation begun?
If Yes, how long ago?

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

Rows	Yes	No
Abnormal Bleeding
Allergies to any drugs
Allergy to latex
Allergy to metals/plastic
Any Hospital Stays
Any Operations
Asthma
Arthritis
Bone Disorders
Cancer
Congenital Heart Defect
Diabetes
Epilepsy/Convulsions
Handicaps/Disabilites
Hearing Impairment
Heart Murmur/Heart Problems
Hemophilia
Hepatitis
HIV +/AIDS
High Blood Pressure
Gastrointestinal Disorders
Genetic Disorders
Kidney / Liver Problems
Neurological Disorders
Neurodivergence/Autism
Psychological/Psychiatric Treatment
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis (TB)

Are there any medical conditions that we have not asked about that you feel we should be aware of?
Emergency Contact

Please list an emergency contact not living with you
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Person that Completed this Form*

First NameLast Name
Relationship to Child
Today's Date*

MonthDayYear
Date
Signature*
For Office Use Only
Form Reviewed By/Date
Should be Empty:

Child Patient Information Form

Custodial Parent Information

Additional Parent Information

Primary Dental Insurance Information

Secondary Insurance

Dental History

Medical History

Emergency Contact