Welcome
to the orthodontist

We would link to welcome you and your child to our office. Our goal is to make every Child`s visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

1Tell Us About Your Child

Today’s Date:

Nickname: CHILD PREFERS TO BE CALLED

Child’s Name:

E-mail Address:

SS#:

Birthdate*:

Age:

Sex

M F

School:

Grade:

Hobbies/Sports:

Child's Home#:

Child's Home Address: APT/CONDO#

CITY

STATE

ZIP

2Who Is Accompanying Your Child Today?

Name:

Relation:

Do you have legal custody of this child?

Yes No

Whom may we thank for referring you?

List brothers / sisters with age:

General Dentist:

Last Visit Date:

Parent’s Marital Status:

Single
Married
Divorced
Widowed
Separated

3

Parent:

Mother
Father
Step Parent
Guardian

Name:

Birthdate:

Email Address:

Cell#:

Hm #:

Employer:

Wk #:

SS:

DL #:

Parent:

Mother
Father
Step Parent
Guardian

Name:

Birthdate:

Email Address:

Cell#:

Hm #:

Employer:

Wk #:

SS:

DL #:

4Person Responsible for Account

Name:

Relation:

Billing Address:

CITY

STATE

ZIP

Previous Address:

CITY

STATE

ZIP

HM #*:

DL #:

Cell #:

SS #:

Employer:

WK #:

Ext:

Who is responsible for making appointments?

Name*:

Wk#:

Ext:

HM #:

5Primary Orthodontic Insurance

Orthodontic Coverage?*

Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

ID #:

Policy Owner’s Employer:

Employer’s Address:

Secondary Orthodontic Insurance

Orthodontic Coverage?

Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

ID #:

Policy Owner’s Employer:

Employer’s Address:

6

What are the main concerns that you would like orthodontics to accomplish?

Has your child ever been prescribed Fosamax

Yes No

or any other bisphosphonate? If yes, when?

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

Yes No

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

Yes No

List any musical instruments played:

Have adenoids or tonsils been removed? Has your child been informed of any

Yes No

missing or extra permanent teeth?

Yes No

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

Yes No

Does your child brush his / her teeth daily?

Yes No

Floss his / her teeth daily?

Yes No

Child's Physician:

Phone#:

Date of Last Visit:

Is your child under the care of a physician?

Yes No

Has puberty begun?

Yes No

Has menstruation begun? (Girls)

Yes No

Please describe your child’s current physical health:

Good Fair Poor

Please list all drugs that your child is currently taking:

Please list all drugs / things that your child is allergic to:

Yes No

Latex

Yes No

Metals/Nickel

Yes No

Plastics

7Has Your Child Ever Had Any Of The Following Medical Problems?*

Yes No

Abnormal Bleeding

Yes No

Convulsions / Epilepsy

Yes No

ADD / ADHD

Yes No

Diabetes

Yes No

Allergies to Any Drugs

Yes No

Handicaps / Disabilities

Yes No

Allergic to Latex / Metals

Yes No

Hearing Impairment

Yes No

Allergic to Plastic

Yes No

Heart Murmur

Yes No

Any Hospital Stays

Yes No

Hemophilia

Yes No

Any Operations

Yes No

Hepatitis

Yes No

Artificial Bones / Joints / Valves

Yes No

HIV+ / AIDS

Yes No

Asperger Syndrome

Yes No

Kidney / Liver Problems

Yes No

Asthma

Yes No

Lupus

Yes No

Autism

Yes No

Rheumatic / Scarlet Fever

Yes No

Cancer

Yes No

Tuberculosis (TB)

Please discuss any medical problems that your child has had:

8Has Your Child Ever Experienced Any Of The Following?*

Yes No

Clenching / Grinding Teeth

Yes No

Nursing / Bottle Habits

Yes No

Lip Sucking / Biting

Yes No

Speech Problems

Yes No

Mouth Breather

Yes No

Thumb / Finger Sucking

Yes No

Nail Biting

Yes No

Tongue Thrust

Neighbor or Relative not living with you

Name

Phone

Address

CITY

STATE

ZIP

9

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 confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

I authorize the dental staff to perform the necessary dental services that my child may need.

Signature of Parent or Guardian

Date

This 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.

Signature of Parent or Guardian

Date

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office.

Signature of Parent or Guardian

Date

Welcome
to the orthodontist

1Tell Us About Your Child

2Who Is Accompanying Your Child Today?

3

4Person Responsible for Account

5Primary Orthodontic Insurance

Secondary Orthodontic Insurance

6

7Has Your Child Ever Had Any Of The Following Medical Problems?*

8Has Your Child Ever Experienced Any Of The Following?*

9

The Parent or Guardian who accompanies the child is responsible for payment.

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.

Welcometo the orthodontist

1Tell Us About Your Child

2Who Is Accompanying Your Child Today?

3

4Person Responsible for Account

5Primary Orthodontic Insurance

Secondary Orthodontic Insurance

6

7Has Your Child Ever Had Any Of The Following Medical Problems?*

8Has Your Child Ever Experienced Any Of The Following?*

9

The Parent or Guardian who accompanies the child is responsible for payment.

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.

Welcome
to the orthodontist