Our doctors and team would like to welcome you and your child to our office! Our goal here at Jacaranda is to make every child’s visit pleasant and educational. We strive to teach good care that will enable your child to have a beautiful smile that lasts a lifetime.

Patient Information

Language Spoken:
Translation Needed?
Braille, TTY or Sign Language Services needed?
Whom may we thank for referring you to our office?
* First Name:
M.I.:
* Last Name:
* Date of Birth:
* Gender:
* Address:
* City:
Apt #:
* State:
* Zip:
How long have you been at this address?
Nickname:
Instagram Name:
Facebook Name:
School:
Grade:
Sports/Hobbies:
List brothers/sisters
Any family members/friends treated in our office?
Who is responsible for making appointments?
Best contact number for making appointments:
Who is accompanying your child today?
Name
Relation:
Do you have custody?
Parental Marital Status:
Mother's Information
Mother's Name:
D.O.B.:
SSN:
Driver's License #:
Address:
Cell:
Home:
Email:
Employer:
Job Title:
Father's Information
Father's Name:
D.O.B.:
SSN:
Driver's License #:
Address:
Cell:
Home:
Email:
Employer:
Job Title:
Person Responsible for Account:

Dental Insurance Information

Carrier: (Aetna, Metlife, etc.)
Phone:
Group #:
Policy Holder Name:
Employer:
D.O.B.:
Social Security #:
I.D. #:

Physician Information

* Is your child under the care of a physician?
Name:
Address:
Phone:
Is your child allergic to any foods? If, yes please list.
* Allergy to any drugs?
Please list all allergies to any medications
Please list all medications that your child is currently taking: (including Tylenon, Multi-Vitamins, or Birth Control)
Please describe your child's physical health:
Has begun puberty:
Has menstruation begun:
* Has your child had their adenoids or tonsils removed?
* Have you ever been told that your child needs to be pre-medicated prior to any dental appointments?
Has your child ever had any of the following medical problems?
* Abnormal Bleeding
* Hemophilia
* Heart Murmur/Seizures
* Allergy to latex/metals
* Convulsions
* Diabetes
* Handicaps/Disabilities
* Operations
* HIV/AIDS
* Kidney/Liver Problems
* Rheumatic/Scarlet Fever
* Hepatitis
* Cancer
* Asthma
* Tuberculosis
* Heart Defects
* Hospital Stays? If yes, explain.
Please discuss any medical problems that your child has:

General Dentist

(If recommended to our office or have had a previous general dentist)

Name of Dentist:
Phone Number:
Date of last visit:
* Have there been any injuries to the face, mouth, teeth, or chin?
* Has your child ever had any pain/tenderness in his/her jaw joint (TMJ)?
Does your child have any of the following habits?
* Teeth Clenching:
* Speech problems
* Tongue Thrusting
* Nursing/Bottle Habits
* Thumb/Finger Sucking
* Lip Biting/Sucking
* Nail Biting
If you are here to see the Orthodontist
What are the min concerns you would like the orthodontist to address/accomplish?
* Has your child ever been evaluated by or treated by an orthodontist before?
List any musical instruments played:
If you are here to see the Pediatric Dentist
* Is this your child’s first visit to the dentist? If no, when was the first visit?
If no, when was the first visit?
Has your child ever had an unfavorable dental experience?
How long since x-rays have been taken? (if at all)
Has your child ever had local anesthetic?
Any unfavorabble reaction to local anesthetic?
Do you live in an area with fluoridated water?
Do you drink/cook with well water?
Does your child use a fluoride rinse?
Does your child floss?
Does your child brush his/her teeth daily?
How would you describe your child’s temperament?
I understand the information I have given is true and correct to the best of my knowledge, it will be held at the strictest of confidence and 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. I understand credit bureau information may be obtained for office payment plans.
Signature of Parent/Guardian:
If 18 years and over, do you have an advanced directive (living will or power of attorney)?

* Agreement to Receive Electronic Communication

I agree that the dental practice may communicate with me electronically at the email address below.

I am aware that there is some level of risk that third parties might be able to read unencrypted emails.

I am responsible for providing the dental practice any updates to my email address.

I can withdraw my consent to electronic communications by calling: 954-452-9988 OR info@jacarandasmiles.com

Patient/Legal Guardian Signature:

* Acknowledgement of Receipt of Notice of Privacy Practices

* You May Refuse To Sign This Acknowledgement *

I have received a copy of this office's Notice of Privacy Practices.
Name:
Signature:

About ICAT CBCT Cone Beam Scans

Jacaranda Orthodontics and Pediatric Dentistry now offers an exciting new technology for our patients and for patients of other doctors who might be referred here. This technology is called I-Cat Cone Beam Computer Assembled Tomography (CBCT) imaging, sometimes called 3-D radiographs or x-rays. Using CBCT means we now have the ability to take 3D images of the teeth, jaws, bones and facial structures at lower costs and with less energy than a typical CT scan used in hospitals. 3D imaging provides us the opportunity of improved diagnosis for our patients, especially in cases of impacted teeth, dental implants, surgical treatment, as well as more complex cases. Understandably you may have questions about exposure to these types of x-rays. Here are some facts you should know about 3-D imaging.

An ICAT CBCT exposure is:

  • About 1/2 as much as a full series of x-rays
  • About 1/5 as much as a full (28) mouth series of standard dental x-rays
  • About 1/70 as much as a typical medical CT scan

CBCT therefore offers our patients enhanced diagnostic value at a significantly reduced exposure. At the same time, CBCT scans can image the entire head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws and surrounding supporting bone, using CBCT’s for those limited purposes.

Our training and dental license does not provide for evaluating and diagnosing outside those areas. However since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull or arteries. We can refer you to a radiology group for this purpose. The average cost is about $ $195.00. If you are interested in taking advantage of this service please initial the application section and sign the acknowledgement below.

YES, I want to have my I-Cat CBCT scans read by an oral radiologist and understand I am responsible for the additional costs.
NO, I understand the risks and benefits of having my CBCT read and interpreted by an oral radiologist, however I knowingly decline such a referral.
Signature of patient/responsible party: