About Your Child

Child's First Name:
Middle Initial:
Last Name:
Patient prefers to be Called:
Birth Date:
Social Security #:
Child's Phone #:
Does child have any siblings or pets?
If Yes, what are their names/ages:
What main concerns do you want to address with orthodontic treatment?
If needed, would you be interested in starting treatment on the same day as the consultation?
If No, explain:
Has your child ever been evaluated or had orthodontic treatment before?
If Yes, explain:
Child’s attitude towards orthodontic treatment:
Has this patient grown in the past year or has their shoe size changed recently?
Whom may we thank for referring/getting you to our office?
How else did you hear about us? (check all that apply)
Please list other family members seen in our office and their relation to this patient:

Responsible Parties or Guardians

Patient lives with:
If Other:
Cell Phone:
Cell Phone:
Responsible Party Name:
Social Security:
Cell Phone:
Preferred appt reminder:

Dental Health Information

Is patient experiencing any dental problems?
Does the patient brush and floss each day?
Has all dental work completed at this time?
If no, please explain:
Name of General Dentist:
Date of last dental visit:
Does patient have or have they had any of the following conditions or problems? (Check those that apply)

Medical Health Information

Is this patient taking any medication at this time?
If yes, please list:
Who should we contact in case of an emergency?
Name of patient’s primary care physician:
Has patient experienced onset of puberty?
If female, has she begun menstruating?
Does patient have or have they had any of the following diseases or conditions? (Check those that apply)
Does patient have any disease, condition, or problem not listed that you think we should know about? Please explain:

Dental Insurance Information

Primary Policy Holder Name:
Date of Birth:
Primary Insurance Company Name:
Subscriber ID:

Secondary Policy Holder Name:
Date of Birth:
Secondary Insurance Company Name:
Subscriber ID:
Do you participate in a flex plan or have a Health Savings Account?
If Yes, Details:
I acknowledge that the above information is correct. I will notify Dr. Tim of any changes that occur after this date. I hereby authorize Dr. Tim and his team to perform an initial orthodontic evaluation/examination.

Guardian Signature: