CHILD/ADOLESCENT PATIENT INFORMATION FORM

TELL US ABOUT YOU:
Last
First
Middle
Who is accompanying you today?
Other family members seen by us:
MOTHER'S INFORMATION:
FATHER'S INFORMATION:
PERSON RESPONSIBLE FOR ACCOUNT:

Please fill out the insurance section only if you have ORTHODONTIC insurance.

PRIMARY ORTHODONTIC INSURANCE:

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

We reserve the right to verify the credit status prior to extending credit for treatment.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein and they are giving consent for new patient exam and any X-rays and/or photographs necessary to complete orthodontic evaluation.