Child Orthodontic Acquaintance Form
Patient Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Birthdate:
Dentist Name:
Referred By?
Billing Information
Title:
First Name:
Middle Initial:
Last Name:
Home Phone:
Work Phone:
Email:
(For Appointment Reminders
)
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental Insurance Information
Insured's Full Name:
Birthdate:
Insured's SSN or ID#:
Patient's Full Name:
Father's Name:
Mother's Name:
Insured's Employer:
Phone:
Dental Insurance Carrier:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Medical History
Has the patient had his or her tonsils or adenoids removed?
No
Yes
Does the patient have disruptive sleep?
No
Yes
Does the patient have any history of major illnesses? If so, please describe.
No
Yes
Does the patient require premedication prior to dental visits?
No
Yes
Does the patient have drug sensitivities or allergic reactions?
No
Yes
If so, please list:
Please list any medications currently being taken by the patient:
Is the patient under medical care now, other than routine?
No
Yes
Physician Name:
Physician Phone:
Please select 'Yes' if the patient has been treated for any of the following.
Diabetes?
No
Yes
Arthritis?
No
Yes
Hearth Trouble/Murmur?
No
Yes
AIDS/ARC?
No
Yes
Asthma?
No
Yes
Epilepsy?
No
Yes
Rheumatic fever?
No
Yes
Sleep Apnea?
No
Yes
Prolonged bleeding?
No
Yes
Nervous disorders?
No
Yes
Hepatitis?
No
Yes
Tuberculosis?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Dental History
Has the patient suffered any severe injury to the face?
No
Yes
*
Has the patient ever sucked his/her thumb or fingers?
No
Yes
If so, until what age?
Are you aware of any missing permanent teeth?
No
Yes
Has the patient had any previous orthodontic treatment?
No
Yes
When did the patient last visit the dentist?
E-Signature:
Date: