We would Like to welcome You and your child to our office. Our mission is to enhance the lives of our patients and their families by providing exceptional orthodontic care with excellent customer a service in. a safe and inviting atmosphere.

Tell Us About Your Child

MaleFemale

Name:Last

First

Nickname:

SS#:

Child's Birthdate:

Child's Age:

Child's Home #:

Child's Home Address:

City

State

Zip

How long at this address:

Previous Address(If less than three years):

City

State

Zip

Whom may we thank for referring you?

General Dentist:

Last Visit:

Responsible Party

MotherFather Step MotherGuardianWidow

Name:

Birthdate:

Address:

Parent's Marital Status:

Single
Widowed
Married
Divorced
Separated

Do you have legal custody of this child?

YesNo

Wk #:

Ext:

Hm #:

Cell #:

SS #:

E-mail:

Employer:

How Long at Current Job:

Job Title:

FatherMother Step FatherGuardianWidow

Name:

Birthdate:

Address:

Do you have legal custody of this child?

YesNo

Wk #:

Ext:

Hm #:

Cell #:

SS #:

E-mail:

Employer:

How Long at Current Job:

Job Title:

Emergency

Name:

Phone:

Address:

City

State

Zip

Nearest Relative not living with you:

Phone:

Relation to Patient:

Address:

City

State

Zip

Dental Insurance

Orthodontic Coverage?

YesNo

Insurance Member ID:

Insurance Co. Name:

Insurance Co. Address:

City

State

Zip

Insurance Co. Phone #:

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate:

SS#:

Policy Owner's Employer:

Secondary Insurance

Orthodontic Coverage?

YesNo

Insurance Member ID:

Insurance Co. Name:

Insurance Co. Address:

City

State

Zip

Insurance Co. Phone #:

Group fl (Plan, Local or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate:

ID #:

Policy Owner's Employer:

What are your specific concerns regarding your child's teeth?

Has your child ever been evaluated or had orthodontic treatment before?

YesNo

Have there been any injuries to the face, mouth, teeth or chin?

YesNo

List any musical instruments played:

Have adenoids or tonsils been removed?

Has your child been informed of any missing or extra permanent teeth?

YesNo

Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD) ?

YesNo

Does your child brush his/her teeth twice daily

YesNo

Floss his / her teeth daily?

YesNo

Is your child currently under the care of a physician

YesNo

Phone #:

Date of last visit:

Has puberty begun?

YesNo

Has menstruation begun? (Girls)

YesNo

Please describe your child's current physical health:

GoodFairPoor

Please list all medications that your child is currently taking:

Please list any allergies:

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

Growth information for Patients Under 16 Years of Age

Adopted

YesNo

Fathers Height:

inch

Mothers Height:

inch

Patient Resemble

Neither ParentMotherFather

Girls: Has she started menstruation

YesNo

When?

Height

inch

Weight

Boys: Has his voice changed?

YesNo

When?

Height

inch

Weight

Name and Ages of Patients Brothers and Sisters:

Have siblings had any orthodontic treatment

YesNo

Has your child ever had any of the following?

Abnormal Bleeding

ADD/ ADHD

Allergies to any Drugs

Allergic to Latex / Metals

Allergic to Plastics

Any Hospital Stays

Any Operations

Artificial Bones /Joints / Valves

Asthma

Cancer

Congenital Heart Defect

Convulsions / Epilepsy

Dental Phobia

Diabetes

Disabilities

Fainting

Hearing Impairment

Heart Murmur

Hemophilia

HIV+ / AIDS

Kidney Problems

Liver Problems

Lupus

Rheumatic / Scarlet Fever

Seizures

Sickle Cell

Disease/ Traits

Tuberculosis (TB)

If you circled yes to any of these please explain further if necessary:

Does / did your child have any of the following habits?

Clenching / Grinding Teeth

Lip Sucking / Biting

Mouth Breather

Nail Biting

Speech Problems

Thumb / Finger Sucking

Tongue Thrust

I understand the information that I have given today is correct and to the best of my knowledge. I also understand that is information will be heldINIIIIr strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the staff to perform any necessary services that the patient may need during diagnosis and treatment.

Signature:

Date:

Name of the person signing

Acknowledgement of Receipt of Notice of Privacy Practices

Saylor & Murphy Orthodontics

* You May Refuse to Sign This Acknowledgment*

I have received a copy of this office’s Notice of Privacy Practices.

Print Name:

Signature:

Date:

Right to Revoke:

I have the right at any time to revoke this Acknowledgement for any reason. I have the right to sign this portionat a later time/dateof my choice to revoke my Acknowledgment.

Signature:

Date:

Name of the person signing