About Your Child
Child's First Name:
Middle Initial:
Last Name:
Patient prefers to be Called:
Birth Date:
Age:
Sex:
M
F
Social Security #:
Child's Phone #:
Grade:
School:
Interest/Hobbies/Sports:
Does child have any siblings or pets?
Yes
No
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?
Yes
No
If No, explain:
Has your child ever been evaluated or had orthodontic treatment before?
Yes
No
If Yes, explain:
Child’s attitude towards orthodontic treatment:
Very Motivated
Will Cooperate (if needed)
Not Motivated
Has this patient grown in the past year or has their shoe size changed recently?
Yes
No
Whom may we thank for referring/getting you to our office?
How else did you hear about us? (check all that apply)
Facebook
Facebook Ads
Magazine
Google
Google Ads
Google Maps
Billboard
Instagram
Other
Please list other family members seen in our office and their relation to this patient:
Responsible Parties or Guardians
Patient lives with:
Both parents together
Both Separately
Mother
Father
Other
If Other:
Father/Guardian:
Cell Phone:
Employer:
Mother/Guardian:
Cell Phone:
Employer:
Responsible Party Name:
Address:
Social Security:
Cell Phone:
Email:
Preferred appt reminder:
Text
E-mail
Both
Dental Health Information
Is patient experiencing any dental problems?
Yes
No
Does the patient brush and floss each day?
Yes
No
Has all dental work completed at this time?
Yes
No
If no, please explain:
Name of General Dentist:
Phone:
Date of last dental visit:
Does patient have or have they had any of the following conditions or problems? (Check those that apply)
Tooth Sensitivity to Heat, Cold, or Sweets
Self Conscious of Smile
Previous Orthodontic Treatment
Tongue Thrust
Finger or Lip Sucking Habit
Fear of Dental Work
Clenching or Grinding
Extra/Missing or Extracted Permanent Teeth
Difficulty Chewing
Clicking or Popping of the Jaw Joints
Medical Health Information
Is this patient taking any medication at this time?
Yes
No
If yes, please list:
Who should we contact in case of an emergency?
Phone:
Name of patient’s primary care physician:
Phone:
Has patient experienced onset of puberty?
Yes
No
If female, has she begun menstruating?
Yes
No
Does patient have or have they had any of the following diseases or conditions? (Check those that apply)
Pregnant/On Birth Control
AIDS, HIV Positive
Diabetes
Heart Defect/Murmur/Disease
Scarlet Fever, Rheumatic Heart Disease
Herpes, Fever Blisters
Stroke
Fainting Spells/Seizures
Allergies (medicine or other)
Joint Replacement or Implant
Asthma
High/Low Blood Pressure
Latex or Nickel Sensitivity/Allergy
Excessive Bleeding or Bruising
Hepatitis
Drug or Alcohol Dependency
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:
SSN:
Date of Birth:
Primary Insurance Company Name:
Subscriber ID:
Group/Plan#:
Secondary Policy Holder Name:
SSN:
Date of Birth:
Secondary Insurance Company Name:
Subscriber ID:
Group/Plan#:
Do you participate in a flex plan or have a Health Savings Account?
Yes
No
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:
Date: