About Your Child

First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
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:
Cell Phone:
Email:
Address:
City:
State:
Zip:
Occupation:
Employer:
Is there a court custody agreement? If yes, please provide agreement.

Emergency Contact Information

Guardian First Name:
Guardian Last Name:
Relationship to Patient:
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?
Does your child have or has he/she had any of the following diseases or conditions?
Allergies (medicine or other)?
AIDS, HIV Positive?
Asthma?
Diabetes?
Drug or Alcohol Dependency?
Excessive Bleeding or Bruising?
Fainting Spells, Seizures?
Heart Defect, Heart Murmur, Heard Disease?
Hepatitis?
Herpes, Fever Blisters?
High/Low Blood Pressure?
Joint Replacement or Implant?
Latex Sensitivity or Allergy?
Metal or Nickel Sensitivity or Allergy?
Scarlet Fever, Rheumatic Heart Disease?
Stroke?
Tonsils or adenoids removed?
FEMALES: Are You Pregnant?
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: