Welcome to the Orthodontist

Child Patient Form
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

1. Tell Us About Your Child

Child's Name
Child's Home Address

2. Who is Accompanying Your Child Today?

Do you have legal custody of this child?
Parent's Marital Status:

3. Parent's Information

Mother's Information


Father's Information


4. Person Responsible For Account

Billing Address
Select if you Own or Rent

Who is responsible for making appointments?

5. Orthodontic Insurance

Primary

Orthodontic Coverage?

Secondary

Orthodontic Coverage?

6. Dental History


Has your child ever taken Phen-Fen?

Has your child ever been evaluated or had orthodontic treatment before?
Has there been any injuries to the face, mouth, teeth or chin?
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Does your child brush his/her teeth daily?
Floss his/her teeth daily?

Is your child currently under the care of a physician?

Has puberty begun?
Girls
Has menstruation begun?
Please describe your child's current physical health:

Is your child allergic to:
Latex
Metals/Nickel
Plastics

7. Medical History

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

ADD/ADHD

Allergies to any Drugs

Allergic to Latex/Metals

Allergic to Plastic

Any Hospital Stays

Any Operations

Artificial Bones/Joints/Valves

Asthma

Cancer

Congenital Heart Defect

Convulsions/Epilepsy

Diabetes

Handicaps/Disabilities

Hearing Impairment

Heart Murmur

Hemophilia

Hepatitis

HIV+/AIDS

Kidney/Liver Problems

Lupus

Rheumatic/Scarlet Fever

Tuberculosis (TB)
Has your child ever experienced any of the following?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb/Finger Sucking
Tongue Thrust

Neighbor or Relative not living with you

Address

Signature

I understand that the information that I have given is correct to the best of my knowlegde, 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 stauts.

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

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

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying and co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

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.

Human Verification

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