Child Patient Health History Form

All sections must be complete prior to submitting.
Patient Information

Names and Ages of Children in Family

Responsible Party Information
Responsible Party Information (Secondary)
Party to be included in patient’s chart for scheduling and appointment matters.

Emergency Information

Dental Insurance
Primary Insurance (if insured's address is different than responsible party, please inform our office)
Secondary Insurance (if insured's address is different than responsible party, please inform our office)

Fee Expectations
Health Questionnaire
General Information
NOW OR IN THE PAST HAS THE PATIENT HAD:

Allergies
Does the patient have allergies to the following

Airway and Sleep Questionnaire
While sleeping, does your child...
Upon awakening, does your child...
Additionally...
Dental History

To the best of my knowledge, the health information is complete and correct. I will not hold Cranford Orthodontics responsible for any errors or omissions that I have made in completing this form. I will notify Cranford Orthodontics of any changes in my medical or dental health. I understand that where appropriate, credit bureau reports may be obtained. I have also received a copy and read the notice of privacy practices.
Thank you for completing the above information. Please only click the “Submit” button once, as it may take a few moments to process. Once successfully submitted, you will be redirected back to the previous page and a confirmation message will appear.