Tell Us About Your Child
Today’s Date: Male Female
Child’s Name: 
Last First MI
Nickname:    SS #:

School:  Grade:

Hobbies/Sports: 
Child’s Home#:  ( )
Child’s Home Address: APT/Condo #
City: State: Zip:
How long have you lived at this address?
Rent or Own?
Birthdate: / /   Age:
     


Who is Accompanying Your Child Today?
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 Widowed Married Divorced Separated


Parent’s Information
Mother’s Information: Step Mother Guardian
Name: Birthdate: / /
Work#: ( ) Ext:  Home# ( )
Cell# ( )
Employer:
Job Title: How long?
SS #: DL#:
 
Father’s Information: Step Father Guardian
Name: Birthdate: / /
Work#: ( ) Ext:  Home# ( )
Employer:
Job Title: How long?
SS #: DL#:
 


Person Responsible for Account
Name:   Relation:
Billing Address: APT/Condo #
City: State: Zip:
Previous Address: APT/Condo #
City: State: Zip:
Work#: ( )   Ext:  Home#: ( )
Employer:
SS #: DL#:
Who is responsible for making appointments?
Name:
Work#: ( )   Ext:  Home#: ( )


Primary Orthodontic Insurance
Primary      
Orthodontic Coverage? Yes No  
Insurance Co. Name:    
Insurance Co. Address:  
Insurance Co. Phone#: ( )    
Group# (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 Co. Name:
Insurance Co. Address:
Insurance Co. Phone#: ( )
Group# (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 orthodontic treatment to address?
Has your child ever been evaluated or had orthodontic treatment before?
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
Please list all drugs that your child is currently taking:
Please list all drugs/things that your child is allergic to:


Has your child ever had any of the following medical conditions?
Y N Abnormal Bleeding Y N Diabetes
Y N Allergies to any Drugs Y N Allergic to Plastic
Y N Handicaps/Disabilities Y N Heart Murmur
Y N Hearing Impairment Y N Any Hospital Stays
Y N Allergic to Latex/Metals Y N Hemophilia
Y N Any Operations Y N Hepatitis
Y N Kidney/Liver Problems Y N Asthma
Y N Rheumatic/ Scarlet Fever Y N HIV +/AIDS
Y N Congenital Heart Defect Y N Tuberculosis (TB)
Y N Convulsions/Epilepsy Y N Cancer
Please discuss any medical problems that your child has had:


Does/did your child have any of the following habits?
Y N Clenching/Grinding Teeth Y N Lip Sucking/Biting
Y N Nursing Bottle Habits Y N Speech Problems
Y N Thumb/Finger Sucking Y N Mouth Breather
Y N Nail Biting Y N Tongue Thrust

Neighbor or Relative not living with you:

Name:   Phone#: ( )

Address: APT/Condo #

City: State: Zip:
 
Please read the information below. Your signature will be required when you arrive at our office to show you unsderstand these terms.

I understand that the information that I have given is correct to the best of my knowledge, that it 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 my child may need.


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 this office, use the services of one or more credit reporting services.


If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.


Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.