Tell Us About Your Child    
Nickname:
*Last Name:  
*First Name:  
Middle Initial:
Email:
Social Security #:
*Birthdate:    
Age:
*Gender:
School:
Grade:
Hobbies/Sports:
*Home #:  
*Home Address:  
*City:  
*State:  
*Zip:  
  Who is Accompanying Your Child Today?   
Name:
Relation:
Do you have legal custody of this child?
Whom may we Thank for referring you?
List brothers/ sisters with age:
Sibling Birthdate:
General Dentist:
Last Visit Date:  
Parent's Marital Status:                 
  Family Information   
Mother's Information
     
Name:
Birthdate:  
Wk #:   Ext: 
Home #:
Employer:
How long at Current Job:
Job Title:
SS #:
DL #:
Father's Information
     
Name:
Birthdate:  
Wk #:   Ext: 
Home #:
Employer:
How long at Current Job:
Job Title:
SS #:
DL #:
  Person Resonsible for Account   
Name:
Relation:
Billing Address:
City:
State:
Zip:
Employer:
Wk #:   Ext: 
Home #:
DL #:
SS #:
Who is responsible for making appointments?
Name:
Wk #:   Ext: 
HM #:
  ORTHODONTIC INSURANCE   
Primary
Orthodontic Coverage:
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:  
Insured's ID #:
Policy Owner's Employer:
Employer's Address:
Secondary
Orthodontic Coverage:
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:  
Insured's ID #:
Policy Owner's Employer:
Employer's Address:
  Dental History     
What are the main concerns that you would like orthodontics to accomplish?
Has your child ever taken Phen-Fen?
If yes, when?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth or chin?
List any musical instruments played:
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain/tenderness in his jaw joint (TMJ/TMD)?
Does you child brush his/her teeth daily?
Floss his/her teeth daily?
Date of last Visit:  
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun? (Girls)
Please list all drugs that your child is currently taking:
Please list all drugs/things that you child is allergic to:
Allergic to:         
   Has your child ever had any of the following medical problems?     
  Abnormal Bleeding
  ADD/ADHD
  Allergies to any Drugs
  Allergic to Latex/Metals
  Allergic to Plastic
  Any Hospital Stays
  Any Operations
  Artificial/Joints/Valves
  Asthma
  Cancer
  Congenital Heart Defect
  Convulsions/Epilepsy
  Diabetes
  Handicaps/Disabilities
  Hearing Impairment
  Heart Murmur
  Hemophilia
  Hepatitis
  HIV+/AIDS
  Kidney/Liver Problems
  Lupus
  Rheumatic/Scarlet Fever
  Tuberculosis (TB)
Please discuss any medical problems that your child has had:
Has your child ever experienced any of the following?
  Clenching/Grinding Teeth
  Lip Sucking/Biting
  Mouth Breather
  Nail Biting
  Nursing Bottle Habits
  Speech Problems
  Thumb/Finger Sucking
  Tongue Thrust
Please list any other drugs/materials that you are allergic to:
  Emergency Contact   
*Name:  
*Phone:  
Parent's Marital Status:                 
  Acknowledgements    
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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that my child may need.
Signature:
Date:  
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.
Signature:                                               Date:                     
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.
Signature:                                               Date: