TELL US ABOUT YOUR CHILD
Today's Date:
Child's Name:
Last Name
First Name
Title
Nickname:
MALE
FEMALE
Child's Birthdate:
Child's Age:
School:
Grade:
Hobbies/Sports:
Home Phone:
Home Address:
Street
City
State
ZIP
E-mail address
ABOUT YOU
Name:
Relation:
Do you have legal custody of this child?:
YES
NO
Whom may we thank for referring you?
List brothers/sisters with age
General Dentist?
Last Visit Date?
Parent's Marital Status:
Single
Married
Divorced
Widowed
Separated
MOTHER'S INFORMATION
Step Mother
Guardian
Name:
Last Name
First Name
Title
Birthdate?:
Work Phone:
Home Phone:
Employer:
How long at current job:
Job title:
SS#:
DL#:
FATHER'S INFORMATION
Step Father
Guardian
Name:
Last Name
First Name
Title
Birthdate?:
Work Phone:
Home Phone:
Employer:
How long at current job:
Job title:
SS#:
DL#:
PERSON RESPONSIBLE FOR ACCOUNT
Name:
Relation:
Billing Address:
Street
City
State
ZIP
Previous Address:
Street
City
State
ZIP
Work Phone:
Home Phone:
Employer:
SS#:
DL#:
Who is responsible for making appointments?
Name:
Work Phone:
Home Phone:
ORTHODONTIC INSURANCE
PRIMARY
Orthodontic Coverage:
YES
NO
Insurance Company Name?:
Insurance Company Address:
Insurance Company Phone #?:
Group Number (Plan, Local, or Policy #):
Policy Owner's Name:
Relationship to patient:
Policy Owner's Birthdate:
SS#:
Policy Owner's Employer:
SECONDARY
Orthodontic Coverage:
YES
NO
Insurance Company Name?:
Insurance Company Address:
Insurance Company Phone #?:
Group Number (Plan, Local, or Policy #):
Policy Owner's Name:
Relationship to Patient:
Policy Owner's Birthdate:
SS#:
Policy Owner's Employer:
WHAT ARE THE MAIN CONCERNS THAT YOU WOULD LIKE ORTHODONTICS TO ACCOMPLISH?
Has your child ever had or been evaluated for orthodontic treatment?:
YES
NO
Have there been any injuries to the face, mouth, teeth or chin?:
YES
NO
List any musical instruments played:
Have adenoids or tonsils been removed?:
YES
NO
Has your child been informed of any missing or extra permanent teeth?:
YES
NO
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)
:
YES
NO
Does your child brush his/her teeth daily?:
YES
NO
Floss his/her teeth daily?:
YES
NO
Child's Physician:
Phone #:
Date of Last Visit:
Is your child currently under the care of a physician:
YES
NO
Has puberty begun:
YES
NO
Has menstruation begun? (girls):
YES
NO
Please describe your child's current physical health:
GOOD
FAIR
POOR
List all drugs that your child is currently taking:
List all drugs that your child is allergic to:
Has your child ever had any of the following diseases or medical problems?
Anemia/Radiation Treatment:
YES
NO
Abnormal Bleeding:
YES
NO
Allergies to any Drugs:
YES
NO
Allergic to Latex/Metals:
YES
NO
Allergy to Plastic:
YES
NO
Any Hospital Stays:
YES
NO
Any Operations:
YES
NO
Asthma:
YES
NO
Cancer:
YES
NO
Congenital Heart Defect:
YES
NO
Convulsions/Epilepsy:
YES
NO
Diabetes:
YES
NO
Handicaps/Disabilities:
YES
NO
Hearing Impairment:
YES
NO
Heart Murmur:
YES
NO
Hemophilia:
YES
NO
Hepatitis:
YES
NO
HIV+/AIDS:
YES
NO
Kidney/Liver Problems:
YES
NO
Rheumatic/Scarlet Fever:
YES
NO
Tuberculosis (TB)s:
YES
NO
Please discuss any medical problems that your child has had:
DOES/DID YOUR CHILD HAVE ANY OF THE FOLLOWING HABITS?
Clenching/Grinding Teeth:
YES
NO
Lip Sucking/Biting:
YES
NO
Mouth Breather:
YES
NO
Nail Biting:
YES
NO
Nursing Bottle Habits:
YES
NO
Speech Problems:
YES
NO
Thumb/Finger Sucking:
YES
NO
Tongue Thrust:
YES
NO
NEIGHBOR OR RELATIVE NOT LIVING WITH YOU
Name:
Phone:
Address:
Street
City
State
ZIP
SIGNATURE
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services that my child may need.
(you will be asked to sign this document on your first visit to our office)
______________________________________________________________
signature
date
THANK YOU FOR FILLING OUT THIS FORM COMPLETELY
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.
(you will be asked to sign this document on your first visit to our office)
______________________________________________________________
signature
date
The parent or Guardian who accompanies the child is responsible for payment.
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.