Child New Patient Information

Child Registration Form - Ortho
* required field

Patient Information

Gender





Primary Phone Number



Parent/Guardian Information

Parent Marital Status

Primary Phone Number
Secondary Phone Number


Primary Phone
Secondary Phone Number


Emergency Contact




Relationship



Other Children in Family







Dental Insurance Information














Dental History


How did you hear about our practice?
Has your child visited an orthodontist before?

Does your child have sores, lumps or irritated areas in the mouth?
Has your child ever been treated for bad bite, TMJ or Periodontal disease?
Does your child you 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?
Is your child frightened or anxious about Orthodontic treatment?
Is your child concerned about the appearance of his or her teeth?
What aspect(s) of dental treatment is your child most concerned with?
Does your child currently or has your child ever had any of the following habits? (select all that apply)
Has there ever been any orthodontic treatment for any other member of the family?






Medical History

Is your child's general health good at this time?



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 taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had tonsils and/or adenoids removed?
Has your child had any serious illnesses or operations?
Does your child have any special problems not listed?
Has your child ever been advised by his or her physician to take an antibiotic prior to any dental treatments?

Has your child shown signs of increased growth recently?



Check if your child has or have ever had any of the following:

Authorization

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION NOT DISCLOSED. I grant authority to the Doctor and Staff to perform all procedures and treatments in the patient's best interest. I understand that, where appropriate, Credit Bureau reports may be obtained. I authorize the Orthodontist to share pertinent treatment information with collaborating dentists and specialists. I authorize the billing of insurance for treatment procedures when appropriate.




Security Measure