New Patient Child Form

PATIENT INFORMATION

Date

PATIENTS FULL NAME*

NICKNAME

Date of Birth*

AGE

Sex

MALE
FEMALE

How did you find us?*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone #

Cell phone #*

Email address*

Referred by

Dentist

Physician

SCHOOL

SCHOOL ADDRESS

FATHER'S(HUSBAND'S)FULL NAME

EMPLOYED BY

BUSINESS ADDRESS

Cell phone #

FATHER'S S.S#

DATE OF BIRTH

BUSINESS PHONE

MOTHER'S(WIFE'S)FULL NAME

EMPLOYED BY

BUSINESS ADDRESS

Cell phone #

MOTHER'S S.S#

DATE OF BIRTH

BUSINESS PHONE

IS PATIENT LIVING WITH BOTH PARENTS?

YES
NO

IF NO, WITH WHOM IS PATIENT LIVING?

DO YOU HAVE ORTHODONTIC DENTAL INSURANCE?

YES
NO

IF YES, NAME OF INSURANCE CARRIER

Group/Policy #

ID #

PERSON RESPONSIBLE FOR THIS ACCOUNT

FATHER
MOTHER
GUARDIAN
OTHER

NAME OF RESPONSIBLE PERSON IF NOT PARENT

BILLING ADDRESS

CITY

STATE

ZIP

PHONE

BROTHER'S AGES

SISTER'S AGES

SPORTS AND HOBBIES

MUSICAL INSTRUMENTS PLAYED

HAS PATIENT EVER HAD ANY PREVIOUS ORTHODONTIC CONSULTATION OR TREATMENT?

YES
NO

REMARKS

HAS ANY OTHER FAMILY MEMBER RECEIVED ORTHODONTIC CARE?

YES
NO

IF YES, WHO?

MEDICAL HISTORY

PLEASE CHECK ANY OF THE FOLLOWING FOR WHICH THE PATIENT HAS BEEN DIAGNOSED OR TREATED: PLEASE COMMENT IF NECESSARY.

WEIGHT

HEIGHT

DOES PATIENT HAVE TENDENCY TO COLDS?

YES
NO

SORE THROATS?

YES
NO

EAR INFECTIONS?

YES
NO

HAVE TONSILS OR ADENOIDS BEEN REMOVED?

WHAT AGE?

ANY BROKEN BONES? PLEASE LIST: DID THEY HEAL SATISFACTORILY?

DOES PATIENT BLEED EASILY?

HAVE HIGH FEVER WITH CHILDHOOD DISEASES?

ANY PSYCHOLOGICAL COUNSELING?

HAS THE PATIENT REACHED PUBERTY?

YES
NO

GIRLS-HAS SHE STARTED MENSTRUATION?

YES
NO

BOYS - HAS HIS VOICE CHANGED?

YES
NO

OTHER ILLNESSES. CONDITIONS. ALLERGIES. ETC:

DID PATIENT EVER HAVE AN ALLERGY TO ANY DRUG OR MEDICATION:

YES
NO

IF YES. REMARKS:

TO THE BEST Of YOUR KNOWLEDGE, IS THE PATIENT IN GOOD HEALTH?

YES
NO

IF PATIENT IS UNDER THE CARE OF A PHYSICIAN FOR A SPECIFIC CONDITION OR IS TAKING ANY MEDICATIONS PLEASE EXPLAIN AND LIST.

DENTAL HISTORY

HAS THE PATIENT HAD ANY INJURIES TO THE FACE?

MOUTH
TEETH
FACE

HAS THE PATIENT EVER SUCKED A THUMB OR FINGERS?

YES
NO

DOES THE PATIENT HAVE ANY SPEECH PROBLEMS?

IS THE PATIENT A MOUTH-BREATHER?

YES
NO

WHILE AWAKE?

WHILE ASLEEP?

YES
NO

HAS THE PATIENT HAD ANY TEETH REMOVED AT ANY TIME BY A DENTIST?

DOES PATIENT (GRIND) THE TEETH OR (BITE) HIS OR HER LIP? PLEASE UNDERLINE

HAVE YOU BEEN INFORMED OF ANY MISSING OR EXTRA PERMANENT TEETH?

DOES FACE AND MOUTH RESEMBLE:

MOTHER
FATHER
NEITHER

DO YOU MAKE REGULAR VISITS TO THE DENTIST?

WHEN LAST?

HOW OFTEN DOES PATIENT BRUSH HIS/HER TEETH?

ANY PAIN IN OR NEAR THE EARS?

RIGHT

LEFT

ANY CLICKING OR DISCOMFORT OF THE JAW JOINT NEAR EARS?

RIGHT

LEFT

DOES PATIENT DESIRE TREATMENT?

IN YOUR OWN WORDS WHAT WOULD YOU LIKE US TO ACCOMPLISH FOR YOUR CHILD?

OTHER RELEVANT INFORMATION:

PARENT OR GUARDIAN'S SIGNATURE

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

I have been informed of your Notice of Privacy of Practice containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time at the above address to obtain a current copy of the Notice of Privacy Practices I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient name

Signature

Relationship to patient

Date

CAPTCHA

ORTHODONTIC REGISTRATION & HEALTH HISTORY QUESTIONNAIRE

PLEASE ANSWER ALL QUESTIONS.

BE ASSURED THAT ALL QUESTIONS ARE NECESSARY AND ALL ANSWERS WILL BE KEPT CONFIDENTIAL