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

Child New Patient Form
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)*

MaleFemale
Identifies As*

She/HerHe/HimThey/Them
Patient's Cell Phone*
Please enter a valid phone number.
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.
Date of Last Cleaning*

MonthDayYear
Date
How Did You Hear About Our Practice?*

AdGoogleSocial MediaFamilyFriendDentistSignageOther
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?*

YESNO
Please list any Immediate Family Members seen in our Office:
Custodial Parent*

First NameLast Name
Relationship*

FatherMotherStep-ParentOther
Date of Birth

MonthDayYear
Employer
Does the patient & guardian live at the same address?*

YesNo
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.
Home Phone Number
Please enter a valid phone number.
Marital Status*

MarriedDivorcedSingleWidow(er)
Spouse's Name

First NameLast Name
Relationship to Patient

FatherMotherStep-ParentOther
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.*

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

YesNo
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have Dental Insurance?

YesNo
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 #
Group #
Employer
Insurance Company Name
Insurance Phone Number
Please enter a valid phone number.
Do you have a Secondary Dental Insurance?

YesNo
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

MonthDayYear
Date
Subscriber ID or Policy Holder Social Security #
Group #
Group #*
Employer
Insurance Company Name
Insurance Phone Number
Please enter a valid phone number.
Dental and Orthodontic History
In your words, what are the main orthodontic concerns?*
Has your child had any previous orthodontic treatment or evaluations?*

YesNo
If so, what was completed, and by whom:
Do you require any prophylactics prior to any dental procedures?

YesNo
If Yes, please explain:
Please check all that apply:*

Pain or discomfort in your jaw joint (past or present)?Teeth Grinding?Speech Problems/tongue thrust?Thumb or finger sucking habits (past or present)?Breath through your mouth while awake?Had an averse reaction during a medical or dental procedure?A family history of jaw size imbalance or missing, impacted, malformed or extra teeth?Have Tonsils/Adenoids Removed?Lip Sucking/Biting?Nail Biting?Chewing/Eating Problem?Treated for or diagnosed with any periodontal problems?None
Has your child experienced serious trauma or injury to the following?*

TeethMouthChinNo Injuries
Medical History
Please check if your child has a history of any of the following:*

AIDS/HIVArtificial Joints or ValvesBlood Pressure ProblemsCancer, Tumor, radiation treatment or chemotherapyConvulsions, Epilepsy or Fainting SpellsDiabetesEndocrine, Thyroid, or Growth ProblemsExcessive bleeding, anemia or bleeding disorderHeadachesHeart Disease or Heart ConditionsHepatitisOsteoporosis/OsteopeniaRheumatoid or Arthritic ConditionsTuberculosisAnxietyADD/ADHDAutism/SensoryLearning/Processing DisabilityNoneOther
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?

YesNo
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)

YESNON/A
Emergency Contact*

First NameLast Name
Relationship to Patient*
Cell Phone Number
Please enter a valid phone number.
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*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Child New Patient Form

Dental and Orthodontic History

Medical History