Child's First Name*
Child's Last Name*
Date of Last Visit
Father's Employer's Phone Number
Mother's Employer's Phone Number
Whom may we thank for referring you to our office?*
Person Responsible For Account
Relation to Child*
Employer Phone Number
Insurance Co. Name
Insurance Co. Phone Number
Policy ID #
Policy Owner's Birthdate:
What are the main concerns that you would like orthodontics to accomplish?
Has your child ever been prescribed Fosamax, or any other bisphosphonate?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been injuries to the face, mouth, teeth or chin?
List any musical instruments played
Have adenoids or tonsils been removed?
Has your child ever been informed of any missing or extra permanent teeth?
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Does your child brush his/her teeth daily?
Floss his/her teeth daily?
Date of Last Visit
Has puberty begun?
Has menstruation begun? (Girls)
Please describe your child's current physical health
Please list all drugs that your child is currently taking
Please list all drugs/things that your child is allergic to
Allergies to Latex?
Allergies to Metals/Nickel?
Allergies to Plastics?
Please check any of the following medical problems your child has experienced: *
Congenital Heart Defect
Any Hospital Stays
Please discuss any medical problems that your child has had
Has your child ever experienced any of the following?
Nursing Bottle Habits
Thumb Finger Sucking
Please check each box to show you understand each statement*
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 of confidence, and it is my responsibility to inform this office of any changes in my child's medical status.
The office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.
I authorize the dental staff to perform the necessary dental services my child may need.
Electronic Signature: *
Date of Completion of Form *