We look forward to seeing you:
at
am / pm
We would appreciate you arriving 10 minutes before the appt time with this form completed.
Jeffery C. Summers, DMD
Today Date :
CHILD FORM
Please take this time to tell us about your child
Name :
First
Middle
Last
Child prefers being called :
Nickname
Male
Female
Child’s Birth Date:
Age :
Home Address :
City :
State :
ZIP :
Home Phone :
Family E-Mail Address:
School :
Grade :
WHO’S ACCOMPANYING THE CHILD TODAY?
Name :
Relation :
Do you have legal custody of the child?
Yes
No
Are there any other family members being seen by Dr. Summers at this time?
What are their names:
Please give names and ages of any other children in the family :
Parental Marital Status :
Single
Married
Widowed
Divorced
MOTHER’S INFO :
Mother
Step-Mother
Guardian
Name :
Birth Date :
Address (if different from child’s) :
State:
Zip:
Work:
Cell :
Employer :
Address :
Occupation :
FATHER’S INFO :
Father
Step-Father
Guardian
Name :
Birth Date :
Address (if different from child’s) :
State:
Zip:
Work:
Work :
Cell :
Drivers License Number :
Employer :
Address :
Occupation :
How did you hear about our office?
Who may we thank for referring you to our office?
INSURANCE
Primary Dental Insurance
Orthodontic Coverage :
Yes
No
Employer :
Insurance Co. Name :
Insurance Co. Address :
Insurance Co. Phone :
Insured Name :
Relation to Patient :
Birth Date :
Member ID #:
SS#:
Fee Expectations
If treatment is recommended for your child, what is your ideal DOWN payment?
$500-$749
$750-$999
$1000+
Pay in full & receive a courtesy discount
If treatment is recommended for your child, what is your ideal MONTHLY payment?
$100-$199
$200-$299
$300-$399
I have an HSA or FSA to use
If treatment is recommended for your child, what is your desired time frame to begin this exciting journey?
ASAP/Today
I would like to get scheduled
Shopping for options
Unsure
PERSON RESPONSIBLE FOR ACCOUNT
Name :
Relationship
Billing Address :
City :
State :
ZIP :
Home :
Cell :
E-mail Address :
Emergency Contact :
Relation :
Home :
GENERAL DENTIST
Name:
Last Dental Exam:
My dentist referred me to:
You
Another Orthodontist
None
Continued on other side...
4207 East North St. Greenville, SC 29615
phone (864) 244-7545
fax (864) 244-7767
www.summersortho.com
MEDICAL HISTORY
A complete history is vital for a proper orthodontic evaluation.
Child’s Physician :
Phone No :
Date of last visit :
Is he/she taking any prescription medication:
Yes
No
If yes, please list which one(s):
GIRLS:
Has puberty begun?
Yes
No
Has menstruation begun?
Yes
No
Is she pregnant?
Yes
No
Is she taking birth control pills?
Yes
No
Has he/she ever had any of the following diseases or medical problems? (Please circle all that apply.)
Abnormal Bleeding
ADD / ADHD
AIDS or HIV positive
Artificial Bones / Joints
Asthma
Birth Defects
Blood Pressure-High or Low
Bone Fractures
Cancer or Tumors
Chest Pain
Congenital Heart Defect
Convulsions
Diabetes
Ear, Nose or Throat
Endocrine or Thyroid
Epilepsy
Excessive Weight Loss/Gain
Fainting Spells, Seizures
Handicap / Disabilities
Hay Fever or Sinus Trouble
Hearing Impairment
Heart Trouble / Murmur
Hepatitis
Immune System
Jaundice or Liver Problems
Kidney Problems
Mental Health / Behavioral
Mitral Valve Prolapse
Neurological Problems
Nose or Throat
Pneumonia
Polio, Mono or Tuberculosis
Prosthetics
Rheumatic or Scarlet Fever
Rheumatoid / Arthritic
Sickle Cell Disease / Traits
Skin Disorders
Speech Difficulties
Stomach Ulcers/Hyperacidity
Swelling Ankles
Vision Difficulties
Are your child’s immunizations current?
Yes
No
Any Hospital Stays / Operations?
Are there any medical conditions we have not discussed that you feel we should be aware of?
MEDICAL ALERT INFORMATION
Does he / she normally require antibiotic pre-medication prior to dental procedures?
Yes
No
Is he / she allergic to any of the following?
Latex
Yes
No
Nickel
Yes
No
Erythromycin
Yes
No
Plastic
Yes
No
Aspirin
Yes
No
Codeine
Yes
No
List any other allergies:
DENTAL HISTORY
Has your child ever been evaluated by an Orthodontist?
Yes
No
If so, by whom?
Has your child ever had orthodontic treatment?
Yes
No
If so, by whom?
Were you happy with the results?
Yes
No
Have other members of the family had orthodontic treatment?
Yes
No
Were you happy with the results?
Yes
No
By whom (if other than Dr. Summers)?
What are your main concerns that you would like orthodontics to correct?
Does your child experience any pain, clicking or discomfort in or near the ears?
Yes
No
Has your child ever had any pain or tenderness in his or her jaw joint (TMJ / TMD)?
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
Yes
No
Have you been informed of missing or extra permanent teeth?
Yes
No
Are you aware of any gum problems?
Yes
No
Have their tonsils or adenoids been removed?
Yes
No
Does/did your child have any of the follow habits? (Please circle)
Clenching / Grinding Teeth
Yes
No
Mouth Breather
Yes
No
Lip Sucking / Biting
Yes
No
Nail Biting
Yes
No
Pacifier User (Until:
age)
Smoking
Yes
No
Thumb / Finger Sucker (Until:
age)
Will the patient comply with wearing their braces or orthodontic appliances?
Yes
No
I hereby certify that I have reviewed the above medical and dental history and agree that it is, to the best of my knowledge, accurate at this time. I am also aware that communication with dentist/specialist may be necessary for treatment. If there are any future changes in this information I will inform the practice of these changes.
Parent / Guardian Signature
Date:
Doctor’s Signature
Date: