PATIENT INFORMATION
Patient Name:
LAST
FIRST
MI
Preferred Name:
Gender:
Male
Female
Non-Binary
Birthdate:
Age:
Home Address:
CITY
STATE
ZIP
Primary Phone Number:
Name of School:
Grade:
Please list any sports and or extracurricular activities including musical instruments played:
Siblings (Names & Ages)
PARENT/GUARDIAN INFORMATION MATERNAL
Name:
LAST
FIRST
MI
Relationship to Patient:
Mother
Step-Mother
Guardian
Other
Marital Status:
S
M
D
W
SO
Address (If different than patient):
CITY
STATE
ZIP
Email:
Primary Phone Number:
Occupation:
Employer:
PARENT/GUARDIAN INFORMATION PATERNAL
Name:
LAST
FIRST
MI
Relationship to Patient:
Father
Step-Father
Guardian
Other
Marital Status:
S
M
D
W
SO
Address (If different than patient):
CITY
STATE
ZIP
Email:
Primary Phone Number:
Occupation:
Employer:
RESPONSIBLE PARTY FOR ACCOUNT
Name:
LAST
FIRST
MI
Relationship to Patient:
Mother
Father
Step-Mother
Step-Father
Guardian
Other
Address (If different than patient):
CITY
STATE
ZIP
Primary Phone Number:
Social Security #:
Birthdate:
PRIMARY DENTAL INSURANCE
Insurance Co. Name:
Insurance Co. Address:
CITY
STATE
ZIP
Insurance Co. Phone:
Group #:
Member ID #:
Policy Holders Name:
Relationship to Patient:
Policy Holders SSN:
Policy Holders Birthdate:
Employer:
SECONDARY DENTAL INSURANCE
Insurance Co. Name:
Insurance Co. Address:
CITY
STATE
ZIP
Insurance Co. Phone:
Group #:
Member ID #:
Policy Holders Name:
Relationship to Patient:
Policy Holders SSN:
Policy Holders Birthdate:
Employer:
DENTAL HISTORY
General Dentist:
Phone:
What was the date of their last visit:
How did you hear about our practice?
Advertisement
Internet
Family/Friend
Dentist
Other
Whom may we thank for referring you (if applicable)?
What are the main concerns that you would like orthodontics to correct?
Has your child visited an orthodontist before?
Yes
No
If yes, date/reason:
Have we treated other family members? If yes, please list their names:
Has your child’s
Tonsils
Adenoids
been removed?
Has your child ever experienced pain/discomfort in their jaw joint (TMJ/TMD)
Yes
No
If yes, please describe left/right or both. AM or PM:
Does your child have any missing or extra permanent teeth?
Yes
No
Has your child ever had injury to the following: (Select all that apply)
Teeth
Jaw
Chin
Please describe injury:
Does your child have speech problems?
Yes
No
If yes, reason:
Do they currently or have they ever had any of the following habits: (Check all that apply)
Clenching/Grinding teeth:
Lip Sucking/Biting:
Thumb/Finger Sucking:
Mouth Breathing:
Tongue Thrusting:
Nail Biting:
Chewing/Eating Problem:
MEDICAL HISTORY
Is your child currently under a physician’s care?
Yes
No
If yes, explain:
Physician:
Phone:
What was the date of their last visit:
Does your child have any allergies or sensitivities? (ie medication, latex, nickel, etc)
Yes
No
If yes, explain:
Is your child taking any medications at this time?
Yes
No
If yes, explain:
Has puberty (males) or menstruation (females) begun?
Yes
No
Has your child had any serious illnesses or operations?
Yes
No
If yes, explain:
Has your child ever had a blood transfusion?
Yes
No
If yes, explain:
Please check if your child has ever had any of the following:
ADD/ADHD
Cough, Persistent
High Blood Pressure
Stroke
Anemia
Coughing Blood
HIV/AIDS
Swelling of Feet or Ankles
Arthritis, Rheumatism
Diabetes
Kidney Disease
Thyroid Problems
Articial Heart Valves
Epilepsy
Liver Disease
Tonsillitis
Articial Joints
Fainting
Mitral Valve Prolapse
Tuberculosis
Asthma
Glaucoma
Pacemaker
Ulcer
Blood Disease
Headaches
Radiation Treatment
Venereal Disease
Cancer
Heart Murmur
Respiratory Disease
Other
Chemotherapy
Heart Problems
Rheumatic Fever
Circulatory Problems
Hemophilia
Scarlet Fever
Cortisone Treatments
Hepatitis
Shortness of Breath
AUTHORIZATION - PLEASE SIGN & DATE
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 oce of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's dental 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 oce. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Signature:
Date: