Confidential Patient Information - Child
*
First Name:
Middle Initial:
*
Last Name:
*
Age
*
Home Phone:
*
Birthdate:
*
Gender:
Male
Female
Other
*
Address:
*
City:
*
State:
*
Zip:
Who is accompanying your child today?
Where does your child go to school?
Grade:
What are some of your child’s favorite activities?
Please let us know how you heard about us (check all that apply):
Community Sponsorship
Community Event
Dentist Referral
Facebook
Family member/Friend
Google
Other Social Media
Other
Road Sign
School Program
List name of referral source:
Custodial Parent Information
*
First Name:
Middle Initial:
*
Last Name:
Marital status:
*
Residence:
*
City:
*
State:
*
Zip:
Mailing Address:
City:
State:
Zip:
Years at this address:
Primary
cell
phone number:
*
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Stepfather
Stepmother
Other
Email:
Employer:
Occupation:
# Years Employed:
Additional parent or contact name:
Relationship to patient:
Employer:
Occupation:
# Years Employed
Birthdate:
Cell Phone:
Dental Insurance Information
Insured’s Name:
Insured’s Social Security #:
Insurance Company:
Group No.:
Insurance Co. Address:
Phone No.:
Policy Holder’s Employer:
Do you have dual coverage?
Yes
No
Insured’s Name:
Insured’s Social Security #:
Insurance Company:
Group No.:
Insurance Co. Address:
Phone No.:
Policy Holder’s Employer:
I have truthfully answered all of the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Brian Potocki to perform and complete an orthodontic evaluation.
Signature:
Date:
Medical History
Physician Name:
Date of Last Visit:
*
Are you taking any medication?
Yes
No
*
Are you allergic to any medication?
Yes
No
*
Are you currently under the care of a physician?
Yes
No
Please check any of the medical conditions that you have had or currently have.
Abnormal bleeding/Hemophilia
Asthma or Hayfever
Fever blisters
High blood pressure
Anemia
Diabetes
Heart Murmur
HIV/Aids
Arthritis
Epilepsy
Hepatitis/liver problems
Prolonged Bleeding
Radiation/Chemotherapy
Are there any other medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist:
Date of Last Visit:
What concerns you most about your teeth?
*
Are you presently in any dental pain?
Yes
No
*
Have you ever experienced any unfavorable reaction to dentistry?
Yes
No
*
Have there been any injuries to face, mouth or teeth?
Yes
No
*
Do your gums bleed when you brush?
Yes
No
*
Do you have any type of thumb or tongue habit?
Yes
No
*
Have you ever seen an orthodontist?
Yes
No
If yes, who & when?
*
What is your attitude towards receiving orthodontic treatment?
*
Are you aware of your jaw clicking or popping?
Yes
No
*
Have you ever been told that you grind your teeth?
Yes
No
*
Do you have tension headaches?
Yes
No
*
Female patients only: Are you pregnant?
Yes
No
*
Parent's Signature:
*
Date: