Tell Us About Your Child

*First Name:
MI:
*Last Name:
Nickname:
*Gender:
*Birthdate:
Age:
Social Security #:
*Address:
*City:
*State:
*Zip:
School:
Hobbies/Sports:

Parent's Information

Marital Status:
Mother's Information
Name:
Occupation:
Cell Phone #:
Work Phone:
Employer:
Length of Employment:
Responsible for account?
If yes, what percent?

Father's Information
Name:
Occupation:
Cell Phone #:
Work Phone:
Employer:
Length of Employment:
Responsible for account?
If yes, what percent?

General Information

General Dentist:
Last Dental Visit:
List Brothers/Sisters, with Ages
Who is Accompanying Your Child Today
Name:
Relation:
Do you have legal custody of this child?
Whom may we thank for referring you?

Orthodontic Insurance

Primary Coverage

Orthodontic Coverage?
Dental Coverage?
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Group # (Plan, Local or Policy#):
Insured's Name:
Relation:
Birthdate:
Insured's ID #:
Insured's Social Security #:
Policy Holder's Employer:

Secondary Coverage

Orthodontic Coverage?
Dental Coverage?
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Group # (Plan, Local or Policy#):
Insured's Name:
Relation:
Birthdate:
Insured's ID #:
Insured's Social Security #:
Policy Holder's Employer:

Emergency Contact

Emergency Contact Name:
Best Contact #:
Relation:

Medical History

What are the main concerns you would like orthodontic treatment to accomplish?
Have you ever taken Fosamax, or any other bisphosphonate?
If yes, please explain:
Has your child ever been evaluated for orthodontic treatment?
Have you ever had an:
List any instruments played:
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had pain/tenderness in his/her jaw joint (TMJ/TMD)?
Floss his/her teeth daily?
Tonsils/Adenoids Removed
Brush teeth daily?
Child's Physician:
Phone Number:
Date of Last Visit:
Is your child currently under the care of a physician?
Has patient begun puberty:
Has menstruation begun: (Girls)
Please describe your child's current health:
Please list all medications that your child is currently taking::
Please list all drugs/ things that your child is allergic to:
Latex
Metal/Nickel
Plastics
Has your child ever had any of the following or medical problems?
Abnormal bleeding?
ADD/ADHD
Allergies to any drugs
Metal or Latex Allergy
Allergic to Plastics:
Any Hopital Stays:
Any Operations:
Artificial Bones/Joints/Valves
Asperger Syndrome
Tuberculosis (TB)
Autism
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV/AIDS
Kidney/Liver Problems
Lupus
Rheumatic/Scarlet
Please discuss any medical problems that your child has had:
Has Your Child Ever Experienced Any of the Following?
Clench or Grind Teeth?
Nail Biting
Lip Sucking/Biting
Mouth Breather
Nursing Bottle Habits
Speech problems?
Thumb/Finger Sucking
Tongue Thrust

General Information

Neighbor or Relative not living with you:
Complete Address:
Phone:
THE PARENTS OR GUARDIAN WHO ACCOMPANIES THE CHILD IS RESPONSIBLE FOR PAYMENT. OUR OFFICE IS HIPAA COMPLIANT AND IS COMMITTED TO MEETING OR EXCEEDING THE STANDARDS OF INFECTION CONTROL MANDATED BY OSHA, THE CDC AND THE ADA.

I understand that the information that I have given today is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

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.