Clone of Papasikos Ortho - Confidential Patient Info (Standard Child Template)

Child's Legal Name

First NameLast Name

Child's Preferred Name, if different

First NameLast Name

Patient's Date of Birth

MonthDayYear

Age

Gender Assigned at Birth (for legal purposes)

Identifies As

Patient's Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Patient's Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Dentist or Practice Name

Practice Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Last Cleaning

Date

How Did You Hear About Our Practice?

Whom Can We Thank for Referring You?

Patient's School & Grade

Please list any sports, interests, or extra curricular activities:

Are any of your immediate family members seen in our office?

Please list any Immediate Family Members seen in our Office:

Custodial Parent

First NameLast Name

Relationship

Other

Date of Birth

MonthDayYear

Employer

Does the patient & guardian live at the same address?

Address, if different than patient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Marital Status

Spouse's Name

First NameLast Name

Relationship to Patient

Are there any legal restrictions that would prevent the non - custodial parent from consenting to or obtaining information about the child's orthodontic treatment? *If yes, a copy of the legal paperwork that supports this restriction must be provided.

Is there anyone else, including additional custodial guardians, that information regarding your child's account and treatment should be shared with?

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Patient

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have Dental Insurance?

Policy Holder

First NameLast Name

Policy Holder Address, if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Subscriber ID or Policy Holder Social Security #

Group #

Employer

Insurance Company Name

Insurance Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have a Secondary Dental Insurance?

Policy Holder

First NameLast Name

Policy Holder Address, if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Subscriber ID or Policy Holder Social Security #

Group #

Employer

Insurance Company Name

Insurance Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

In your words, what are the main orthodontic concerns?

Has your child had any previous orthodontic treatment or evaluations?

If so, what was completed, and by whom:

Do you require any prophylactics prior to any dental procedures?

If Yes, please explain:

Please check all that apply:

Has your child experienced serious trauma or injury to the following?

Please check if your child has a history of any of the following:

If you answered yes to any of the above, please explain in more detail. If you answered "None" please write N/A below:

Allergies (latex, codeine, penicillin, metal, anesthetics, other). Please write in any allergies that you have.

Are you under the care of a physician for a specific condition not listed above?

If yes, please describe:

Is your child taking any medications? If yes, please provide medications and the dosage:

Females: Is the patient pregnant (need to know for x-rays)

Emergency Contact

First NameLast Name

Relationship to Patient

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the orthodontist to help determine appropriate and helpful orthodontic treatment. I also understand that if there is any change to my, or the above named patient's dental or medical status, it is my responsibility to inform the doctor.

Signature

Date

Child New Patient Form

Dental and Orthodontic History

Medical History