Child Patient Form

TELL US ABOUT YOUR CHILD
Please print this form and bring it with you to your appointment.

Today's Date:

* Child's Name:

LAST FIRST MI

Nickname:

* E-Mail Address: * SS #

* Birthdate: * Age: * Male Female

* School: * Grade:

Hobbies / Sports:

* Child's Hm #:

* Child's Home Address:

APT/CONDO #

* City: * State: * Zip

WHO WILL BE ACCOMPANYING YOUR CHILD TO OUR OFFICE?

* Name: * Relation:

* Do you have legal custody of this child? Yes No

Whom may we Thank for referring you?

List brothers / sisters with age:

Names: Ages:

* General Dentist:

* Last Visit Date:

* Parent's Marital Status:

Single Married Partnered Separated Divorced Widowed

If divorce is involved, who is the custodial parent?

May patient information be released to the noncustodial parent? Yes No

PARENTAL/GUARDIAN INFORMATION

Mother's Information Step Mother Guardian

* Name: * Birthdate:

Wk #: Ext: * Hm #:

Employer:

How Long at Current Job: Job Title:

* SS #: DL #:

Father's Information Step Father Guardian

* Name: * Birthdate:

Wk #: Ext: * Hm #:

Employer:

How Long at Current Job: Job Title:

* SS #: DL #:

PERSON RESPONSIBLE FOR ACCOUNT

* Name: Relation:

Billing Address:

* City: * State: * Zip

Previous Address:

* City: * State: * Zip

* Who is responsible for making appointments?

Mom Dad Accompanying Guardian

Wk #: Ext: Hm #:

ORTHODONTIC INSURANCE

Primary

* Orthodontic Coverage Yes No

* If yes was selected for Orthodontic Coverage,
the following are required

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate Policy Owner's SS #:

Policy Owner's Employer:

Employer's Address

Secondary

* Orthodontic Coverage Yes No

* If yes was selected for Orthodontic Coverage,
the following are required

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate Policy Owner's SS #:

Policy Owner's Employer:

Employer's Address

GENERAL QUESTIONS

* What are the main concerns that you would like orthodontics to accomplish?

* Has your child ever taken Phe-Fen?
(Also known as Redux or Pondimin) Yes No

If yes, when?

* Has your child ever been evaluated
for or had orthodontic treatment? Yes No

* Has your child ever had an injury to their: Mouth Teeth Chin

List any musical instruments played:

* Have adenoids or tonsils been removed? Yes No

* Has your child been informed of any
missing or extra permanent teeth? Yes No

* Has your child ever had any pain / discomfort in his/her
jaw joint (TMJ/ TMD)? Yes No

* Does your child brush his/her teeth daily? Yes No

* Floss his/her teeth daily? Yes No

* Child's Physician:

* Phone #: * Date of last visit:

* Is your child currently under the care of a physician? Yes No

* Has puberty begun? Yes No

* Has menstuation begun (Girls)? Yes No

* Please describe your child's current physical health:
Good Fair Poor

Please list all drugs that your child is currently taking:

Please list any other drugs / things that your child is allergic to:

Patient's attitude toward orthodontic treatment:

Very motivated Will cooperate if needed Not motivated

YOUR CHILD'S MEDICAL HISTORY

Has your child ever had any of the
following medical problems?

Abnormal Bleeding
ADD / HDD
Allergies to any Drugs
Allergic to Latex / Metals
Allergic to Plastic
Any Hospital Stays
Any Operations
Artificial Bones / Joints / Valves
Asthma
Cancer
Congenital Heart Defect

Convulsions / Epilepsy
Diabetes
handicaps / Disabilities
Hearing Impairment
Heart Murmor
Hemophilia
Hepatitis
HIV+ / AIDS
Kidney / Liver Problems
Rheumatic / Scarlet Fever
Tuberculosis (TB)

Please discuss any medical problems that your child has had:

MEDICAL/DENTAL HISTORY

Has your child ever had any of the
following medical problems?

Clenching / Grinding Teeth
Lip Sucking / Biting
Mouth Breather
Nail Biting

Nursing Bottle Habits
Speech Problems
Thumb / Finger Sucking
Tongue Thrust

Neighbor or Relative not living with you:

* Name: * Phone:

* Address:

* City: * State: * Zip

I understand that the information that I have given is correct to the best of my knowledge, that it wil be held in the strictest of 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 the necessary dental services my child may need. 3/9/2010 You must check this box above and enter your name, stating that you understand and agree to the statement above.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. 3/9/2010 You must check this box above and enter your name, stating that you understand and agree to the statement above.	If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. 3/9/2010 You must check this box above and enter your name, stating that you understand and agree to the statement above.