Child Patient Information 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
2 digit month, 2 digit day, 4 digit yearDate
Child's Sex
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?
Please enter names of other family members seen by us:
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
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
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
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
2 digit month, 2 digit day, 4 digit yearDate
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 number.Format: (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 Holder's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder's SSN
We may need this to verify your policy
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

If you would prefer to send us images of your insurance card, please take clear photos of the front and back of the card, and upload here. Otherwise, please proceed to the next section to fill in your insurance information
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Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.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 Dental Insurance Information
Policy Holder's Name

First NameLast Name
Policy Holder's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder's SSN
We may need this to verify your policy
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

If you would prefer to send us images of your insurance card, please take clear photos of the front and back of the card, and upload here. Otherwise, please proceed to the next section to fill in your insurance information
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Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.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
Has your child ever seen an orthodontist?
If yes, who?
When?
Have there been any injuries to the face, teeth, jaw, mouth, or chin? If yes, 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/Grinding Teeth
Lip Biting/Sucking
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
Is your child currently under the care of a physician for any specific conditions?
If yes, please explain:
Please list any 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 menustration 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 or plastics
Any Hospital Stays
Any Operations
Asthma
Arthritis
Bone Disorders
Cancer
Congenital Heart Defect
Diabetes
Epilepsy/Convulsions
Handicaps/Disabilities
Hearing Impairment

Rows	Yes	No
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
Please enter a valid 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
2 digit month, 2 digit day, 4 digit yearDate
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 Dental Insurance Information

Dental History

Medical History

Emergency Contact