Child New Patient Information

Patient Information

Patient Name*

Gender

Male

Female

Social Security Number

Birth Date

Age

Home Address

City

State

Zip

Primary Phone Number *

Phone type

Home

Cell

School

Grade

List any sports or extracurricular activities

Siblings (names and ages)

Parent/Guardian Information

Relationship

Parent Name

Social Security Number

Birth Date

E-mail Address

Drivers License Number

Address (if different than childs)

City

State

Zip

Primary Phone Number

Phone type

Home

Cell

Secondary Phone Number

Phone type

Home

Cell

Employer

Occupation

Untitled

Name

Social Security Number

Birth Date

Drivers License

Address (if different than childs)

City

State

Zip

Phone

Phone type

Home

Cell

Secondary Phone Number

Phone type

Home

Cell

Occupation

Employer

Emergency Contact

Emergency Contact Name (other than parent)

Phone Number

Relation to child

Address

City

State

Person(s) OK to release appointment or medically related information to concerning child.

Relation

Dental Insurance Information

Primary Insurance Company

Policy Holders Name

Insurance Phone Number

Group Number

Member ID Number

Relation

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Subscriber Holders Name

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Dental History

General Dentist

Last Visit

Name of person referring (if applicable)

What are the main concerns you would like orthodontics to accomplish?

Has your child visited an orthodontist before?

Yes

No

When?

Reason?

Has your child's tonsils or adenoids been removed?

Yes

No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes

No

Does your child you have any missing or extra permanent teeth?

Yes

No

Has your child ever had an injury to (select all that apply):

TeethMouthChin

Does your child have speech problems?

Yes

No

If so, explain:

Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?

Yes

No

Reason

Physician

Deductible (if known)

Phone

Does your child have any allergies/sensitivities to medications or latex?

Yes

No

If yes, please list allergies:

Is your child currently taking any prescription or over-the-counter medications?

Yes

No

Please list, with dosage:

Has puberty and/or menstruation begun?

Yes

No

Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes

No

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?

Yes

No

If yes, give approximate dates:

Is your child pregnant?

Yes

No

Nursing?

Yes

No

Taking birth control pills?

Yes

No

Authorization

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 the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party

Date

Required field*