Child new patient form

"*" indicates required fields

Patient Information

Sex:

Birth Date:
Patient's Address:

Parent / Guardian Information

Parent 1
Birth Date:
Parent 2
Birth Date:

Emergency Contact Information

Emergency Contact Address (if different from patient):

Referral Information

Primary Insurance Information

Policy Holder's Date of Birth:

Secondary Insurance Information

Policy Holder's Date of Birth:

Dental History

Has your child visited an orthodontist before?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Do your child's gums bleed?
Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

Is your child currently being treated by a physician?*
Does your child have any allergies/sensitivities to medications or latex?*
Is your child currently taking any prescription or over-the-counter medications?*
Has puberty and/or menstruation begun?
Has your child ever had a blood transfusion?*
Check if your child has or has ever had any of the following:

Authorization

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 office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical 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 office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Date