TELL US ABOUT YOUR CHILD
Today's Date:
Child's First Name:
Middle Initial:
Last Name:
Nickname:
Gender:
Male
Female
Child's Birthdate:
Age:
School:
Grade:
Child's Home #:
Child's Home Address:
City:
State:
Zip:
Child's Hobbies?
WHO IS ACCOMPANYING YOUR CHILD TODAY?
Name:
Relation:
Do you have legal custody of this child?
Yes
No
Whom may we thank for referring your child?
Other family members seen in our office:
Child's Dentist:
Last Visit Date:
Parent's Marital Status:
MOTHER'S INFORMATION
Relation to Child:
Mother
Stepmother
Guardian
Name:
Birthdate:
Work #:
Ext:
Cell #:
Email Address:
Employer:
Job Title:
FATHER'S INFORMATION
Relation to Child:
Father
Stepfather
Guardian
Name:
Birthdate:
Work #:
Ext:
Cell #:
Email Address:
Employer:
Job Title:
PERSON RESPONSIBLE FOR ACCOUNT
Name:
Relation:
Billing Address:
City:
State:
Zip:
Work #:
Ext:
Home #:
Cell #:
Email:
SSN:
WHO IS RESPONSIBLE FOR SETTING UP APPOINTMENTS WITH US?
Name:
Best way to reach you?
PRIMARY
ORTHODONTIC
INSURANCE
Insurance Co. Name:
Policy Holder:
Address:
ID or SSN#:
GR#:
SECONDARY
ORTHODONTIC
INSURANCE
Insurance Co. Name:
Policy Holder:
Address:
ID or SSN#:
GR#:
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
MEDICAL HISTORY
What is your primary reason for seeing the orthodontist today?
HAS YOUR CHILD EVER EXPERIENCED ANY OF THE FOLLOWING MEDICAL PROBLEMS?
Bleeding / Clotting disorder?
No
Yes
Bleeding / Clotting disorder?
No
Yes
Convulsions / Epilepsy
No
Yes
Handicaps / Disabilities
No
Yes
Any hostpital stays
No
Yes
Hearing Impairment
No
Yes
Any surgeries
No
Yes
ADD / ADHD
No
Yes
Artificial bones / joints / valves
No
Yes
Hepatitis
No
Yes
Asthma
No
Yes
HIV+ / AIDS
No
Yes
Cancer
No
Yes
Kidney / Liver problems
No
Yes
Congenital heart defect
No
Yes
Rheumatic / Scarlet fever
No
Yes
Heart murmur
No
Yes
Sickle Cell Disease
No
Yes
Diabetes
No
Yes
Tuberculosis
No
Yes
Drug reaction
No
Yes
Latex or Metal allergy
No
Yes
Missing or extra teeth
No
Yes
Trauma to mouth/teeth/jaws
No
Yes
Other medical problem(s)
No
Yes
DOES YOUR CHILD EXHIBIT (OR HAS EVER HAD) ANY OF THE FOLLOWING HABITS?
Lib sucking or biting
No
Yes
Nail biting
No
Yes
Teeth grinding/clenching
No
Yes
Thumb/finger sucking
No
Yes
Tongue thrusting
No
Yes
Mouth Breathing
No
Yes
Has your child ever seen or been under the care of an orthodontist?
No
Yes
Has your child ever had a serious/difficult experience associated with previous dental work?
Yes
No
Is your child currently under the care of a physician
Yes
No
If yes, please give name and phone:
Please describe your child's current physical health:
Good
Fair
Poor
Please list all the drugs your child is currently taking:
Please list all the drugs your child is allergic to:
I understand that 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 or Guardian:
Date:
I authorize the dental staff to perform the necessary orthodontic services my child may need.
Signature of Parent or Guardian:
Date:
The Parent or Guardian who accompanies the chid is responsible for payment at the time of service, unless prior arrangments have been approved by our Business Manager.