Parent/Guardian 1 Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Parent/Guardian 2:

First Name

Last Name

Relationship to Patient:

Parent/Guardian 2 Date of Birth:

Parent/Guardian 2 Phone Number:

Parent/Guardian 2 Email Address:

Parent/Guardian 2 Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Child's Name:

First Name

Last Name

Preferred Name (nickname):

Date of Birth:

Child's Gender:

Child's School (if applicable):

Pediatrician's Name:

First Name

Last Name

Pediatrician's Phone Number:

Pediatrician's Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please check any medical conditions your child has or had:

Please list any other medical conditions not listed above:

Is your child currently taking any medications (prescription and/or over-the-counter)?

YesNo

Please list all medications (prescription and/or over-the-counter) your child is taking including name of medication, dosage, and frequency:

Does your child have any medication allergies?

YesNo

Please list all medication(s) your child is allergic to and type of allergic reaction:

Does your child have any other allergies (latex, nickel, food)?

YesNo

Please list allergy and reaction:

Has your child ever been hospitalized or had surgery?

YesNo

If your child has been hospitalized, please list reason why. Please also list any surgeries your child has had:

Does your child currently use any tobacco/nicotine products (cigarettes, vaping, chewing tobacco)?

YesNo

Does your child use any recreational drugs?

YesNo

Has your child been seen by a dentist?

YesNo

If yes, please list the name of your child's dentist:

First Name

Last Name

If yes, please list the date of the last dental visit:

Please check any dental treatment your child has had:

Dental Cleaning

Dental X-rays

Fluoride Treatment

Dental Filling

Crown

Extraction

Laughing Gas (Nitrous oxide)

Orthodontic Treatment (braces)

How many times per day are your child's teeth brushed?

1x/day

2x/day

3x/day

Do you help brush your child's teeth?

Yes

Sometimes

Does your child use toothpaste with fluoride (most major brand toothpastes contain fluoride)?

Yes

Sometimes

Don't Know

Does your child use mouthwash/mouthrinse with fluoride?

Yes

Sometimes

Don't Know

Does your child floss daily?

Yes

Sometimes

Does your child currently have a dental problem or dental pain?

Yes

If yes, please describe the dental problem or dental pain? How long?

Please list any dental or orthodontic concerns you have about your child's teeth:

Typed Signature of Parent/Guardian:

By typing your name to use as your electronic signature, you are verifying that the information provided to Jonquil Orthodontics and Pediatric Dentistry is accurate and that you will notify the office of any changes in your child's medical or dental status.

Dental Insurance Information

PRIMARY Insured's Name:

First Name

Last Name

PRIMARY Insured's Employer:

PRIMARY Insured's Date of Birth:

PRIMARY Insured's Relationship to Patient:

PRIMARY Insured's Social Security Number or Member ID Number:

Insurance Company Name:

Insurance Company Phone Number:

Do you have dual dental insurance coverage? If yes, please answer questions below for secondary insurance.

YesNo

SECONDARY Insured's Name:

First Name

Last Name

SECONDARY Insured's Employer:

SECONDARY Insured's Date of Birth:

SECONDARY Insured's Relationship to Patient:

SECONDARY Insured's Social Security Number or Member ID:

Secondary Insurance Company Name:

Secondary Insurance Company Phone Number:

Secondary Insurance Group Number:

Typed Signature of Parent/Guardian:

By typing your name to use as your electronic signature, you are giving Jonquil Orthodontics and Pediatric Dentistry permission to file insurance on your behalf for orthodontic/dental services and payment of any benefits to the office. You also understand that you are responsible for any amount not covered/paid by your insurance.

HIPAA Information

A copy of our HIPAA policy is on the website and available upon request.

Patient Name:

First Name

Last Name

Patient Date of Birth:

The following person may contact Jonquil Orthodontics and Pediatric Dentistry regarding the above patient:

First Name

Last Name

Relationship to Patient:

The following person may contact Jonquil Orthodontics and Pediatric Dentistry regarding the above patient:

First Name

Last Name

Relationship to Patient:

Acknowledgement of HIPAA Policy (available on website and upon request):

Acknowledged

Typed Signature of Parent/Guardian

By typing your name as your electronic signature as the parent/guardian of the above patient, you are giving consent for Jonquil Orthodontics and Pediatric Dentistry to use your/your child's protected health information to carry out treatment, payment, and other related healthcare operations.

Relationship to Patient:

Appointment/Scheduling Policy

Available on website and upon request.

Acknowledgement of Appointment/Scheduling Policy (available on website and upon request):

Acknowledged

How did you hear about our office?

By clicking "Submit", you certify that all of the above information is correct and accurate to the best of your knowledge. If any of the above information changes, you will contact our office promptly to advise of the changes.

Medical/Dental History Form

Responsible Party

Patient Information

Dental History Form

Dental Insurance Information

HIPAA Information

Appointment/Scheduling Policy