Child Medical and Dental History

Child Medical and Dental History
Patient and Family Information
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Siblings Names / Ages
School
Mother Name

First NameMiddle NameLast Name
Mother Marital Status
Mother Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother Email
example@example.com
Mother Employer
Father Name

First NameMiddle NameLast Name
Father Marital Status
Father Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father Email
example@example.com
Father Employer
Other Legal Guardians (if applicable)
Primary Insurance Information
Insurance Name
Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber Name

First NameMiddle NameLast Name
Subscriber ID
Subscriber Social Security
Subscriber DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Group Plan
Ortho Coverage
Patient/Guardian Signature
Secondary Insurance Name
Secondary Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Subscriber Name

First NameMiddle NameLast Name
Secondary Subscriber ID
Secondary Subscriber Social Security Number
Secondary Subscriber DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Group Plan
Secondary Ortho Coverage
Patient/Guardian Signature
Dental History and Orthodontic Concerns
Dentist Name

First NameLast Name
Dentist Street Address
Dentist City
Dentist State
Last Dental Visit Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Last Dental Visit
Previous Orthodontic Exam/Evaluation
Dental History Conditions

Other
Other (please specify)
Main Orthodontic Concern
Interested In
Interested In - Other (please specify)
Referral and Medical History
How did you hear about us?
Physician Name

First NameMiddle NameLast Name
Physician Street Address
Physician City
Physician State
Currently Taking Any Medications
Medications and Conditions (if yes)
Allergies (medication/food/etc.)
Premedicate with Antibiotics for Dental Procedures
Premedication Details (if yes)
Medical History Conditions

Other Medical Problem Not Listed
Other Medical Problems Not Listed
I have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of the form. I will notify my orthodontist of any changes to my medical or dental health.
Patient/Guardian Signature
Should be Empty:

Child Medical and Dental History

Patient and Family Information

Primary Insurance Information

Dental History and Orthodontic Concerns

Referral and Medical History