Child Patient Form

Patient Information

Patient Name:

Gender:

MaleFemale

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type:

homecell

OK to leave message?

YesNo

E-mail:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Parent 1

Name:

Social Security Number:

Birth Date:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type:

homecell

Secondary Phone:

Phone Type:

homecell

Employer's Name:

Occupation:

Parent 2

Name:

Social Security Number:

Birth Date:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type:

homecell

Secondary Phone:

Phone Type:

homecell

Employer's Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Dental Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

General Dentist:

Last Visit:

Name of person referring (if applicable):

What are the main concerns you would like orthodontics to correct?

Has your child visited an orthodontist before?

YesNo

If yes, when?:

Reason:

Have we treated any other family members?

YesNo

Name:

Have your child's tonsils or adenoids been removed?

YesNo

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo

Does your child have any missing or extra permanent teeth?

YesNo

Has your child ever had an injury to (select all that apply):

TeethMouthChin

Does your child have speech problems?

YesNo

If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

Is your child currently being treated by a physician?

YesNo

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex?

YesNo

If yes, please list:

Is your child currently taking any prescription or over-the-counter medications?

YesNo

If yes, please list with the dosage:

Has puberty and/or menstruation begun?

YesNoNA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?

YesNo

If yes, give approximate dates:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date:

Acknowledgement of Privacy Practices

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996(HIPAA).I understand that this information can and will be used to:

Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers for my health care services.
Conduct normal health care operations such as quality assessments and improvement activities.

I have been informed of my dental provider’s NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such NOTICE OF PRIVACY PRACTICES. I may contact this office at the address above to obtain a current copy of the NOTICE OF PRIVACY PRACTICES.

I understand that I may request in writing that you restrict how my private information is used of, disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my required restrictions, but if you do agree, then you are to abide by such restrictions.

Patient Name(PRINTED):

Date:

Signature:

Other family members covered by this acknowledgement:

ADDITIONAL DISCLOSURE AUTHORITY:

ANY MEMBER OF MY IMMEDIATE FAMILY:

YesNo

SPOUSE ONLY:

YesNo