CHILD/ADOLESCENT PATIENT INFORMATION FORM

TELL US ABOUT YOUR CHILD:

LAST
FIRST
MI

Other family members seen by us:

MOTHER'S INFORMATION:

FATHER'S INFORMATION:

PERSON RESPONSIBLE FOR ACCOUNT:

Is the patient Allergic to any of the following?

Does the patient have or had any of the following habits?

Does the patient have or ever had any of the following?

Sleep/Airway Issues :

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

We reserve the right to verify the credit status prior to extending credit for treatment.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein.
I will not hold the orthodontist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. I understand that I am responsible for the payment of services rendered and for paying and co-payment and deductibles that my insurance does not cover.