New Patient (Child)

Patient Form (Children)

CONFIDENTIAL PATIENT INFORMATION
Name
First Last
Sex
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Birthdate
Month
Day
Year
If patient is a minor, with whom does the patient reside?
Relationship to Patient
Patient's Dentist
Date of Last Appointment
Month
Day
Year
Whom may we thank for referring you to our office?
Please list any family members who have had treatment in our office
Please list any interests or hobbies
CONFIDENTIAL RESPONSIBLE PARTY INFORMATION
Name
First Last
Marital Status
Residence
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long at this address
Previous City/State (if less than 3 years)
Please provide the primary email address for parent(s)
Home Phone
Work Phone
Cell Phone
SSN
Relationship to Patient
Employer
Occupation
Years Employed
Spouse's Name (if applicable)
First Last
Relationship to Patient
Employer
Occupation
Years Employed
SSN
Birthdate
MM slash DD slash YYYY
Work Phone
Cell Phone
DENTAL / ORTHODONTIC INSURANCE INFORMATION
Policy Holder's Name
First Last
SSN
Policy Holder's Date of Birth
MM slash DD slash YYYY
Member ID #
Insurance Company
Insurance Company Phone
Policy Holder's Employer
Do you have dual coverage?
- Yes
- No
If yes, please complete below.
Policy Holder's Name
First Last
SSN
Policy Holder's Birthdate
Month
Day
Year
Member ID #
Insurance Company
Insurance Company Phone
- I understand that where appropriate, credit bureau reports may be obtained.
Date
Month
Day
Year
CONFIDENTIAL MEDICAL AND DENTAL HISTORY
Has your child ever had any of the following medical problems?
Check all that apply.
- Abnormal Bleeding
- Allergies to any drugs
- Allergy to latex
- Any hospital stays
- Any operations/surgery
- Asthma
- Cancer
- Chronic sinus problems
- Congenital heart defect
- Convulsions/Epilepsy
- Diabetes
- Endocrine/Growth disorders
- Handicaps/Disabilities
- Hearing impairment
- Heart murmur
- Hemophilia/Blood disorders
- Hepatitis
- HIV/AIDS
- Kidney/Liver problems
- Nickel allergy
- Rheumatic/scarlet fever
- Tonsils/adenoids removed
- Tuberculosis
- Other
Is your child currently under the care of a physician for any medical problems?
- Yes
- No
Please discuss any YES answers in the space provided
Please describe your child's current physical health
- Good
- Fair
- Poor
Date of your child's last physical
Month
Day
Year
Child's Physician
Please list any drugs/medications that your child is taking
Does your child have any of the following habits?
Check all that apply.
- Clenching or grinding teeth
- Lip sucking or biting
- Mouth breathing
- Nail biting
- Smoking
- Nursing bottle habit
- Speech problems and/or speech therapy
- Thumb or finger sucking
- Tongue thrust
What are the main concerns that you would like orthodontic treatment to address?
- Has your child ever been evaluated or had orthodontic treatment before?
- Has your child ever received an injury to the face, mouth, teeth, or chin?
- Have you been informed about any missing or extra permanent teeth?
- Has your child ever had any pain, tenderness, and/or clicking in the temporomandibular joint (TMJ)?
Please discuss YES answers to the above questions
Does your child have good oral hygiene habits?
- Yes
- No
Does your child see a general dentist regularly for check-ups?
- Yes
- No
Please make any other comments that you feel may be helpful

New Patient (Child)

Patient Form (Children)

CONFIDENTIAL PATIENT INFORMATION

CONFIDENTIAL RESPONSIBLE PARTY INFORMATION

DENTAL / ORTHODONTIC INSURANCE INFORMATION

CONFIDENTIAL MEDICAL AND DENTAL HISTORY