About Your Child
First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
How did you hear about our office?
Who is your dentist?
Please list other IMMEDIATE family members seen in our office and their relation to you?
Responsible Party Information
First Name:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Cell Phone:
Email:
Address:
City:
State:
Zip:
Occupation:
Employer:
Is there a court custody agreement? If yes, please provide agreement.
Yes
No
Emergency Contact Information
Guardian First Name:
Guardian Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Cell Phone:
Dental Insurance Information
Primary Insurance
Insurance Company Name:
Group/Plan Number:
Insurance Company Phone:
Policy Holder's Name:
Social Security #/Member ID:
Birthdate:
Secondary Insurance
Insurance Company Name:
Group/Plan Number:
Insurance Company Phone:
Policy Holder's Name:
Social Security #:
Birthdate:
Medical Health Information
What is the reason you are seeking an orthodontic evaluation?
Have you seen an orthodontist previously?
Yes
No
Does your child have or has he/she had any of the following diseases or conditions?
Allergies (medicine or other)?
Yes
No
AIDS, HIV Positive?
Yes
No
Asthma?
Yes
No
Diabetes?
Yes
No
Drug or Alcohol Dependency?
Yes
No
Excessive Bleeding or Bruising?
Yes
No
Fainting Spells, Seizures?
Yes
No
Heart Defect, Heart Murmur, Heard Disease?
Yes
No
Hepatitis?
Yes
No
Herpes, Fever Blisters?
Yes
No
High/Low Blood Pressure?
Yes
No
Joint Replacement or Implant?
Yes
No
Latex Sensitivity or Allergy?
Yes
No
Metal or Nickel Sensitivity or Allergy?
Yes
No
Scarlet Fever, Rheumatic Heart Disease?
Yes
No
Stroke?
Yes
No
Tonsils or adenoids removed?
Yes
No
FEMALES: Are You Pregnant?
Yes
No
If you responded yes to any question, please explain:
Does your child have any disease, condition, or problem not listed that you think we should know about? Please explain.
Please list any medications currently being taken by the patient (include non-prescription):
Signature:
Date: