Spielberg Orthodontist Child Form

Our goal is to help your child reach and maintain good oral health and a beautiful smile that lasts a lifetime.

1Tell Us About Your Child

Today’s Date:

Nickname:

Child’s Name: Last

First

Middle

M F

Birthdate:

Age:

SS #:

School:

Grade:

Hobbies / Sports:

Child’s Home #

Child’s Home Address:

CITY

STATE

ZIP

E-mail Address:

2Who is Accompanying Your Child Today?

Name:

Relation:

Do you have legal custody of this child?

Yes

Whom may we thank for referring you?

List other family members seen by us

General Dentist:

Date of last cleaning / visit:

Parent’s Marital Status:

Single Partnered Divorced Married Separated Widowed

3Parental Information

Mother Stepmother Guardian

Name:

Birthdate:

Wk #

Hm #

Employer:

How long at current job:

Job Title:

SS #:

DL #:

Father Stepfather Guardian

Name:

Birthdate:

Wk #

Hm #

Employer:

How long at current job:

Job Title:

SS #:

DL #:

4Person Responsible for Account

Name:

Relation:

Billing Address:

CITY

STATE

ZIP

Previous Address:

CITY

STATE

ZIP

Hm #

DL #:

Employer:

Wk #

SS #:

Who is responsible for making appointments?

Name:

Wk #

Cell #

Hm #

5Primary Orthodontic Insurance

Orthodontic Coverage?

Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

ID #:

Policy Owner’s Employer:

Employer’s Address:

Secondary Orthodontic Insurance

Orthodontic Coverage?

Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

ID #:

Policy Owner’s Employer:

Employer’s Address:

6What would you like orthodontics to accomplish?

Has your child ever taken Phen-Fen?

Y N

(Redux or Pondimin) If yes, when?

Has your child ever been evaluated or had orthodontic treatment before?

Y N

Have there been any injuries to the face, mouth, teeth or chin?

Y N

List any musical instruments played:

Have adenoids or tonsils been removed?

Y N

Has your child been informed of any missing or extra permanent teeth?

Y N

Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?

Y N

Does your child brush his / her teeth daily?

Y N

Does your child floss his / her teeth daily?

Y N

Child’s Physician:

Phone #

Date of last visit:

Is your child under the care of a physician?

Y N

Has puberty begun?

Y N

Girls - Has menstruation begun?

Y N

Please describe your child’s current

physical health:

Good Fair Poor

Please list all drugs that your child is currently taking:

Please list all drugs/things that your child is allergic to:

Latex

Y N

Metals/Nickel

Y N

Plastics

Y N

7Has your child ever had any of the following medical problems?

Y N

Abnormal Bleeding

Y N

Convulsions / Epilepsy

Y N

ADD / ADHD

Y N

Diabetes

Y N

Allergies to Any Drugs

Y N

Handicaps / Disabilities

Y N

Allergic to Latex / Metals

Y N

Hearing Impairment

Y N

Allergic to Plastic

Y N

Heart Murmur

Y N

Any Hospital Stays

Y N

Hemophilia

Y N

Any Operations

Y N

Hepatitis

Y N

Artificial Bones / Joints

Y N

HIV+ / AIDS

Y N

Artificial Valves

Y N

Kidney / Liver Problems

Y N

Asthma

Y N

Lupus

Y N

Cancer

Y N

Rheumatic / Scarlet Fever

Y N

Congenital Heart Defect

Y N

Tuberculosis (TB)

Please discuss any medical problems that your child has had:

8Has your child ever experienced any of the following?

Y N

Clenching / Grinding Teeth

Y N

Nursing / Bottle Habits

Y N

Lip Sucking / Biting

Y N

Speech Problems

Y N

Mouth Breather

Y N

Thumb / Finger Sucking

Y N

Nail Biting

Y N

Tongue Thrust

Neighbor or Relative not living with you

Name

Ph #

Address

CITY

STATE

ZIP

9

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

I authorize the dental staff to perform the necessary dental services that my child may need.

SIGNATURE OF PARENT OR GUARDIAN

Date:

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

SIGNATURE OF PARENT OR GUARDIAN

Date:

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office.

SIGNATURE OF PARENT OR GUARDIAN

Date:

Our goal is to help your child reach and maintain good oral health and a beautiful smile that lasts a lifetime.

1Tell Us About Your Child

2Who is Accompanying Your Child Today?

3Parental Information

4Person Responsible for Account

5Primary Orthodontic Insurance

Secondary Orthodontic Insurance

6What would you like orthodontics to accomplish?

7Has your child ever had any of the following medical problems?

8Has your child ever experienced any of the following?

9

The Parent or Guardian who accompanies the child is responsible for payment.

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