Child New Patient Information

Child Registration Form - Medical
* required field

Patient Information

Gender





Primary Phone Number




Parent/Guardian Information

Marital Status






Phone Number
Secondary Phone Number








Phone
Secondary Phone Number

Emergency Contact








Insurance Information

























Dental History


How did you hear about our Practice?Internet
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?

Has your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
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?
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?



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 any serious illnesses or operations? If yes, describe
Has your child ever had a blood transfusion?



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

Authorization

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 of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained and give permission for diagnostic records to be taken which may be used for educational or promotional materials. Our office respects your privacy and will provide you with our Notice of Privacy Practices upon request.


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