FOR CHILDREN: WELCOME TO OUR PRACTICE
Patient Information
First Name:
Middle Initial:
Last Name:
Gender assigned at birth:
Male
Female
Choose not to disclose
DOB:
Age:
Preferred Name:
Hobbies/Special Interests:
Address:
City:
State:
Zip:
Phone:
Cell:
School:
Grade:
Name of General Dentist:
Phone:
Name of other family members treated at Orthodontics LTD:
Whom may we thank for referring you?
Parent/Guardian 1's Information
Name:
DOB:
SSN:
Address:
City:
State:
Zip:
How long at this address?
Previous Address:
Email:
Phone:
Cell:
Employer:
Years employed:
Occupation:
Relationships Status:
Single
Married
Separated
Divorced
Widowed
Other:
Spouse's Name:
Parent/Guardian 2's Information
Name:
DOB:
SSN:
Address:
City:
State:
Zip:
How long at this address?
Previous Address:
Email:
Phone:
Cell:
Employer:
Years employed:
Occupation:
Relationship Status:
Single
Married
Separated
Divorced
Widowed
Other:
Spouse's Name:
Additional Responsible Party Information -
If Applicable
(i.e. Step-Parent, Legal Guardian)
Name:
Relationship:
DOB:
SSN:
Employer:
Address:
City:
State:
Zip:
E-mail:
Phone:
Cell:
Relationship Status:
Single
Married
Separated
Divorced
Widowed
Other:
Emergency Contact Information
Nearest Relative Not Living with You:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Complete Address:
Do you authorize Orthodontics Ltd. to obtain a consumer credit report when appropriate?
I
AUTHORIZE
ORTHODONTICS LTD. TO OBTAIN A CONSUMER CREDIT REPORT WHEN APPROPRIATE.
I
DO NOT
AUTHORIZE ORTHODONTICS LTD. TO OBTAIN A CONSUMER CREDIT REPORT.
SIGNATURE OF PARENT/GUARDIAN:
DATE:
Primary Dental Insurance
Insurance Co. Name:
Insured's Name:
Insurance Phone:
Group/Policy #:
SSN/ID#:
Insured's DOB:
Relationship to Patient:
Insured's Employer:
Secondary Dental Insurance
Insurance Co. Name:
Insured's Name:
Insurance Phone:
Group/Policy #:
SSN/ID#:
Insured's DOB:
Relationship to Patient:
Insured's Employer:
Patient Dental/Medical History
Why have you come to the Orthodontist today?
Has the child ever had a serious/difficult problem associated with dental work?
Yes
No
Has the child been seen by an ENT?
Yes
No
Have the tonsils/adenoids been removed?
Yes
No
Is the child's water fluoridated?
Yes
No
Is the child taking fluoridated supplements?
Yes
No
Has the child ever had pain/tenderness in the jaw joint?
Yes
No
Has the child ever had trauma to the mouth/iaw joint?
Yes
No
Does the child have a history of speech problems/therapy?
Yes
No
Does the child brush teeth daily?
Yes
No
Has the child ever had orthodontic treatment?
Yes
No
Has the child ever been treated with antibiotics prior to a routine dental appointment? If yes please describe:
Is the child currently under the care of a physican?
Yes
No
Explain:
Child's Physician:
Phone:
Last Visit:
Please describe the child's health:
Good
Fair
Poor
Please list all drugs the child is currently taking:
Please list all drugs the child is allergic to:
Please discuss any serious medical problems:
Heart Murmur
Yes
No
Cancer
Yes
No
Diabetes
Yes
No
Rheumatic Fever
Yes
No
HIV+\AIDS
Yes
No
Hemophilia
Yes
No
Asthma
Yes
No
Hepatitis
Yes
No
Tuberculosis
Yes
No
Prosthesis
Yes
No
Allergy to metal
Yes
No
Allergy to latex
Yes
No
Drug Allergies
Yes
No
Major Accidents
Yes
No
Arthritic Conditions
Yes
No
Osteoporosis
Yes
No
Whiplash Injury
Yes
No
Congenital Heart Defect
Yes
No
Convulsions/Epilepsy
Yes
No
Abnormal Bleeding
Yes
No
Hearing Impairment
Yes
No
Any Operations
Yes
No
Kidney/Liver Problems
Yes
No
Handicaps/Disabilities
Yes
No
History of Scarlet Fever
Yes
No
ADD/ADHD
Yes
No
DOES THE CHILD HAVE ANY OF THE FOLLOWING HABITS?
Thumb/Finger Sucking
Yes
No
Lip Sucking
Yes
No
Mouth Breathing
Yes
No
Snoring
Yes
No
Nail Biting
Yes
No
Abnormal Swallowing
Yes
No
Bed Wetting
Yes
No
I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations.
Initials
I consent to the knowledge of video surveillance throughout the premises of Orthodontics LTD. for security purposes.
Initails:
I understand the information that I have given 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.
Signature of Parent/Guardian:
Date: