PATIENT INFORMATION
FOR PATIENTS UNDER 18
Patient's Name
*
First Middle Last
Preferred Name
Birthdate
*
-
Month
-
Day
Year
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Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Responsible Party Cell Phone #
*
-
Area Code
Phone Number
Secondary Phone #
-
Area Code
Phone Number
Patient's School and Grade
Sports / Clubs / Hobbies
Whom may we thank for referring you to our office
*
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RESPONSIBLE PARTY
Primary Responsible Party
*
First Name
Last Name
Relationship to Patient
*
Father
Mother
Step Father
Step Mother
Grandparent
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
*
/
Month
/
Day
Year
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Cell Phone#
*
-
Area Code
Phone Number
Social Security #
Email
*
Marital Status
*
Single
Married
Separated
Divorced
Widowed
If Married, Spouses Name
Employer
Occupation
Years Employed
Second Responsible Party
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Patient
Father
Mother
Step Father
Step Mother
Grandparent
Other
Birthdate
-
Month
-
Day
Year
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Cell Phone#
-
Area Code
Phone Number
Social Security #
Email
Marital Status
Single
Married
Separated
Divorced
Widowed
If Married, Spouses Name
Employer
Occupation
Years Employed
Do You Have Dental Insurance?
*
Yes
No
DENTAL INSURANCE INFORMATION
PRIMARY DENTAL INSURANCE
Primary Dental Insurance Company
Example: Delta Dental of California
Dental Insurance Phone#
-
Area Code
Phone Number
Subscriber's Name
First Name
Last Name
Subscriber's Date of Birth
/
Month
/
Day
Year
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Subscriber's Relationship to Patient
Father
Mother
Step Father
Step Mother
Grandparent
Other
Subscriber's Employer
Group #
Subscriber's ID # or Social Security #
Subscriber's Address (If different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber's Phone Number
-
Area Code
Phone Number
Do You Have a Secondary Dental Insurance?
Yes
No
SECONDARY DENTAL INSURANCE
*IF APPLICABLE
Second Dental Insurance Company
Example: Delta Dental of California
Insurance Phone#
-
Area Code
Phone Number
Subscriber's Name
First Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
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Subscriber's Relationship to Patient
Father
Mother
Step Father
Step Mother
Grandparent
Other
Choose One
Subscriber's Employer
Group #
Subscriber's ID# or Social Security #
Subscriber's Address (If different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber's Phone Number
-
Area Code
Phone Number
EMERGENCY CONTACT
Nearest Relative Not Living with Patient
*
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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DENTAL HISTORY
Dentist Name
*
Approximate Date of Last Dental Visit
*
/
Month
/
Day
Year
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Has your child had prior orthodontic treatment, please explain when and where
*
Main reason for seeking Orthodontic Treatment
*
Has your child experienced the following
*
Rows
Yes
No
Grind or clench teeth
Gums bleed when brushing
Frequent headaches
Oral habits (thumb/finger sucking, lip/nail biting)
Neck/shoulder pain
Mouth breathing
Have missing or extra permanent teeth
Been diagnosed with Gum Disease or Periodontitis
Is any part of the mouth sensitive to temperature or pressure
Food catches in between teeth
Have any soreness around the eyes or ears
Have unpleasant odor or taste in the mouth
Any pain on teeth, face, or jaw
Ever had an injury to the mouth, teeth, chin, or jaw
Any pain, popping, or clicking of jaw joint
Jaw feels like it locks
If any of the above dental questions were answered 'Yes', please explain
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MEDICAL HISTORY
Primary Care Physician Name
*
Approximate Date of Last Physical
*
/
Month
/
Day
Year
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Address
Phone Number#
-
Area Code
Phone Number
Has your child experienced any of the following
*
Rows
Yes
No
Rheumatic Fever
Kidney Problems
Tuberculosis/Lung Disease
Liver Disease
Heart Disease/Heart Murmur
* Is Pre-Medication Required
Heart Attack/Stroke
Congenital Heart Disease
Heart Surgery/Pace Maker
Mitral Valve Prolapse
Pain/Pressure/Tightness in Chest
Hemophilia/Abnormal Bleeding
High Blood Pressure
Low Blood Pressure
HIV/AIDS
Hepatitis
Diabetes
Seizures/Epilepsy
Asthma
Sinus/Breathing Problems
Psychiatric/Learning Problems
ADHD
Major Operations
Cancer/Chemotherapy/Radiation
Adenoids/Tonsils Removed
Artificial Bones/Joints
VD (Syphilis, Gonorrhea)
Please check all that apply to your child
*
Rows
Yes
No
Currently pregnant
On Birth Control
Uses thyroid medications
Uses anxiety medications
On a prescribed Diet
Born premature
Uses Dilatin or Equivalent
Uses Hormones (Including birth control)
Uses Bisphosphonate Medications
Has Genetic Disorders
Other Medical Conditions
Is your child taking Medications for
*
Rows
Yes
No
Diabetes
Nerves (Tranquilizers/Relaxants)
Sleeping
Heart
Blood Pressure
Blood (Liver, Iron Pills)
Stomache Trouble
Headaches
Allergies
Other Medications
Are you aware of any Allergies
*
Rows
Yes
No
Latex/Rubber Gloves
Metal/Nickel
Aspirin/Codeine
Sulfa Drugs
Penicillin/Tetracycline/Erythromycin
Other Allergies
Is there anything else you would like us to know about your child?
SIGNATURE
By signing below, I certify that the information provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my medical health. I authorize Bailey Orthodontic's Staff to perform necessary dental services that I may need during diagnosis and treatment. I hereby authorize my insurance benefits to be paid directly to Bailey Orthodontics office and I authorize Bailey Orthodontics to release any information to process insurance claims.
*
Responsible Party Signature
Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit
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