Welcome to the
Orthodontist!
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. Print This Form, Complete and Bring to Your First Appointment
About Your Child
Orthodontic Insurance (Primary)
Today's Date
Male Female
Orthodontic Coverage Yes
No
Child's Name: Last
First
Middle
Insurance Co Name:
Nickname:
Insurance Co Address:
Birthdate
/ / Age:
Insurance Co Phone #
( )
School:
Grade:
Group # (plan, local or policy #)
Hobbies / Sports
Policy owner's name:
Child's Home Address
Relation to Patient
City
State
Zip
Policy owner's birthdate
/ /
Policy owner's SS#
Hm#: ( )
Policy owner's Employer:
Who is Accompanying Your Child Today?
Secondary Insurance
Name:
Relation:
Orthodontic Coverage Yes
No
Do you have legal custody of this
child? Yes
No
Dental Coverage Yes
No
Whom
may we thank for referring you?
Insurance Co Name:
List brothers / sisters with age:
Insurance Co Address:
General
dentist:
Last visit date:
Insurance Co Phone #
( )
Parental Marital Status: Single Married DivorcedWidowed Separated
Group # (plan, local or policy #)
Mother's Information StepmotherGuardian
Policy owner's name:
Name:
Birthdate
/
/
Policy owner's birthdate
/
/
Wk# ( )
Ext: Hm#: (
)
Policy owner's SS#
Employer:
Policy owner's Employer:
How long at current job?
Job Title:
SS#
DL#
What are the main
concerns that you would like orthodontics to accomplish?
Father's InformationStepfatherGuardian
Name:
Birthdate
/
/
Has your child ever
been evaluated or had orthodontic treatment? Yes
No
Wk# ( )
Ext: Hm#: (
)
Employer:
Has your child ever had an injury to
the face?
Mouth ChinTeeth
How long at current job?
Job Title:
List any musical instruments:
SS#
DL#
Have adenoids or tonsils been
removed? Yes
No
Person Responsible for Account
Medical History
Person Responsible for Account:
Physician's Name:
Billing Address:
Phone#: ( )
Date of last visit:
City
State
Zip
Has puberty begun? Yes No
Previous Address
Has menstruation begun?(Girls)
Yes No
City
State
Zip
Is your child's current health
is: Good
Fair Poor
Hm#: ( )
DL#
Are you currently under the care of
a physician? Yes No
Wk# ( )
Ext:
SS#
Please explain:
Who is responsible for making appointments?
Is your child taking any
prescription / over the counter medication?
Name:
Yes, No
List each one:
Wk# ( )
Ext: Hm#: (
)
Dental History
Medical History Continued
Your child's current dental health
is:Good Fair Poor
Have you ever had any of the
following diseases or medical problems?
Does your child brush his/her teeth
daily? Yes No
Y
N
Abnormal bleeding
Y
N
Diabetes
Floss his / her teeth daily? Yes No
Y
N
Allergies to any drugs
Y
N
Handicaps / Disabilities
Has your child been informed of any
extra or permanent teeth?
Yes No
Y
N
Allergic to Latex / Metals
Y
N
Hearing Impairment
Has your child ever had any
pain / tenderness in his / her jaw joints (TMJ / TMD)? Yes No
Y
N
Allergic to Plastic
Y
N
Heart Murmur
Y
N
Any hospital stays
Y
N
Hemophilia
Does / did your child have any of the following
habits?
Y
N
Any operations
Y
N
Hepatitis
Y
N
Clenching / grinding teeth
Y
N
Nursing Bottle Habits
Y
N
Asthma
Y
N
HIV+ / AIDS
Y
N
Lip Sucking / Biting
Y
N
Speech Problems
Y
N
Cancer
Y
N
Kidney/ Liver Problems
Y
N
Mouth Breather
Y
N
Thumb / Finger Sucking
Y
N
Congenital Heart Defect
Y
N
Rheumatic / Scarlet Fever
Y
N
Nail Biting
Y
N
Tongue Thrust
Y
N
Convulsions / Epilepsy
Y
N
Tuberculosis (TB)
Please list any serious medical
condition(s) that your child has ever had:
Neighbor or Relative not living with you:
Name:
Phone: (
)
Address
City
State
Zip
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 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 any
necessary dental services that my child may need.
Signature of parent or
guardian
Date
Thank You for filling out this form completely.
This office
reserves the right to verify the credit status of potential patients and / or parents of
patients prior to extending credit for treatment or fees and may, at the discretion of the
office, use the services of one or more credit reporting services.
If this office
accepts insurance, I understand that I am responsible for payments of services rendered
and also responsible for paying any co-payment and deductibles that my insurance does not
cover.
Signature
Date
Signature
Date
Our office is committed to meeting or exceeding the standards of infection
control mandated by OSHA, the CDC and the ADA.
OFFICE USE ONLY OFFICE USE ONLY
OFFICE USE ONLY
I verbally reviewed the medical / dental
information above with the parent / guardian and patient named herein.
Initials:
Date: