Tell Us About Your Child

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Main Phone is Landline or Cell:
Email:
School:
Grade:
Other Family Members Seen by us:
Hobbies/Sports:
General Dentist Name:
Date of last cleaning/visit:
Previous orthodontic exam?
Chief Complaint?
Who is Accompanying Your Child Today:
Do you have legal custody of this child?

Person Responsible for Account

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Relationship to Patient:
Main Phone:
Work Phone:
Driver's License #:
Social Security Number:
Employer:

Person Responsible for Making Appointments

First Name:
Middle Initial:
Last Name:
Main Phone:
Cell Phone:
Work Phone:

Parental Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Main Phone:
Work Phone:
Employer:
Job Title:
Social Security Number:
Driver's License #:
First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Main Phone:
Work Phone:
Employer:
Job Title:
Social Security Number:
Driver's License #:

Insurance Information

Primary Insurance

Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Relationship to Patient:
Birthdate:
Subscriber ID:
Group Number:
Policy Holder's Employer:
Employer Address:

Secondary Insurance

Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Relationship to Patient:
Birthdate:
Subscriber ID:
Group Number:
Policy Holder's Employer:
Employer Address:
Signature:
Date