We would like to welcome you and your child to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Patient Information

Gender:

Parents' Information

Father's Information

Marital Status:

Mother's Information

Marital Status:

Insurance Information

Do you have Dual Coverage?:

General Information

Medical History

Is the child currently under the care of a physician?:
Has puberty begun?:
Has menstruation (period) begun?
Has the patient ever been evaluated for orthodontic treatment?:
Have the patient's tonsils or adenoids been removed?:
Has the patient ever experienced jaw joint pain/discomfort (TMJ/TMD)?:
Does the patient have any missing or extra permanent teeth?:
Has the patient ever had an injury to: (select all that apply)
Has the patient ever had any of the following habits?
Does the patient have speech problems?:
Is the child allergic to any of the following?

Signature

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

I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor, and I authorize payment of any insurance benefits to the office. I understand that where appropriate, credit bureau reports may be obtained.

Human Verification

Please enter the verification codes listed below to continue with submitting your form.