Childrens Patient Form

SAVE TIME! Please use the form below to fill out your child's patient information online and you will be able to submit a copy directly to our office, as well as print a copy for your records.

This is an ONLINE FORM. Please fill out the following form as completely as possible. Fields marked with an asterisk are required. Once you have filled out the application you will be able to save/preview a copy and then submit the form securely to our office. After you have completed the form please check the information for accuracy and then click the submit button at the bottom of the page. If you prefer to print the form out, complete it by hand and submit it manually to us, click here.

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PATIENT INFORMATION

Child's Name *
Full Mailing Address * (Street Address, City, State, Zip)
Home Phone
Date of Birth
 Social Security Number
Parent/Guardian's Name *
Social Security Number
 Date of Birth
 Email *
Parent's Full Mailing Address * (Street Address, City, State, Zip)
School Attending
 Grade
Who may we thank for referring you?
 General Dentist

RESPONSIBLE PARTY INFORMATION

Name *
 Marital Status
Residence
Full Mailing Address * (Street Address, City, State, Zip)
 Years at This Address
Previous Address (if less than 3 years) (Street Address, City, State, Zip)
Home Phone
Work Phone
Cell Phone
Social Security Number
 Date of Birth
 Email
Employer
 Occupation
 Years Employeed
Who may we thank for referring you?
 General Dentist
Spouse's Information
Name
 Date of Birth
Relationship to Patient
Home Phone
Work Phone
Social Security Number
Employer
 Occupation
 Years Employeed

ORTHODONTIC INSURANCE INFORMATION

Insured's Name
 Date of Birth
 Insured's Social Security #
Insurance Company
 Group #
 Policy #
Insurance Company Address (Street Address, City, State, Zip)
Do you have dual coverage? Yes No     If yes, please fill out secondary insurance info below:
Insured's Name
 Date of Birth
 Insured's Social Security #
Insurance Company
 Group #
 Policy #
Insurance Company Address (Street Address, City, State, Zip)
1st Insured's Employer
 2nd Insured's Employer

GENERAL DENTAL HISTORY

What are your chief concerns?
Describe what you would like orthodontics to accomplish.
Has your child been evaluated or had orthodontic treatment? Yes No
Have there been any injuries to your child's face mouth, teeth or chin? Yes No
Have you or your child been informed of any missing or extra permanent teeth? Yes No
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)? Yes No
Is your child currently under the care of a physician? Yes No
Child's Physician
 Phone
 Date of last visit
Please describe your child's current physical health
Good    Fair    Poor
Please list any medications/drugs that your child is currently taking:

Allergies
Aspirin Yes No Any metals/plastics Yes No
Latex Yes No Codeine Yes No
Dental Anesthetics Yes No Erythromycin Yes No
Penicillin Yes No Tetracycline Yes No
Other Allergy 1 Other Allergy 2
Please list any other medication/drugs, foods, or materials (ie. latex or nickle) that your child is allergic to:
Does your child need to take medication before seeing his/her dentist? Yes No
If yes, what?

Has your child ever had any of the following?
Abnormal Bleeding Yes No Mitral Valve Prolapse / Heart Murmur Yes No
Allergies to any drugs Yes No Hemophilia Yes No
Congenital Heart Defect Yes No HIV+ / Aids Yes No
Diabetes Yes No Hepatitis / Liver Disease Yes No
Tuberculosis(TB) Yes No Allergic to Latex / Metals Yes No
Convulsions / Epilepsy Yes No Allergic to Plastic Yes No
Handicaps / Disabilities Yes No

Has your child ever had any of the following habits?
Clinching / Grinding Teeth Yes No Lip Sucking / Biting Yes No
Mouth Breather Yes No Nail Biting Yes No
Nurse bottle habits Yes No Speech problems / habits Yes No
Thumb / Finger Sucking Yes No Tongue Thrust Yes No
Have you ever had speech therapy? Yes No

if yes please describe:

EMERGENCY INFORMATION

Name of nearest relative not living with you
 Relationship
Complete Address (Street Address, City, State, Zip)
 Phone
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