Child New Patient Form

Submit your health history form online to your orthodontist today.

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

TELL US ABOUT YOUR CHILD

Patient's Full Name *

Patient's Sex:

Siblings and Ages

1
2
3

MOTHER'S INFORMATION

Mother's Middle Name

Mother's Social Security #

Does Mother have legal custody of this child?

Yes

FATHER'S INFORMATION

Father's Middle Name

Father's Social Security #

Does Father have legal custody of this child?

Yes

What is the primary concern for orthodontic evaluation? *

SO THAT WE MAY BETTER SERVE YOU, PLEASE FILL OUT THE QUESTIONNAIRE BELOW.

When choosing orthodontic treatment, what is important to you? Please rank the options below with 5 being extremely important and 1 not important.

1= Not Important

2= Somewhat important

3= Important

4= Very Important

5= Extremely important

The length of the treatment

Comfort during the treatment

The use of the latest technology

Aesthetics in the treatment

Having a low initial fee

Having a low monthly fee

The quality of treatment

BadGood

If treatment is recommended, how interested are you in starting treatment today or within the next 30 days?

Whom may we thank for referring you to our office? - Select all that apply.

Please Specify Below:

PARENTS’ MARITAL STATUS

Please place a check by the appropriate answer

Who will be responsible for the bill?

Mother

Father

Both

List any family members that have been treated by our office (if applicable):

1
2
3
4

PATIENT'S MEDICAL HISTORY

Physician’s Full Name

Date of the last Visit

Is the patient taking any medications (include over-the-counter)?

Yes

Patient's current health is:

Good

Fair

Poor

Do you have a history of any of the following? - Select all that apply *

Please discuss any other medical problems below:

Please explain any of the "yes" answers above:

Have adenoid and/or tonsils ever been removed?

Yes

In order to gauge growth, has puberty begun?

Yes

Girls: Has menstruation begun?

Yes

Is the patient allergic to any of the following? *

Please list any other medicine or material the patient may be allergic to:

Allergy 1
Allergy 2
Allergy 3
Allergy 4

PATIENT'S DENTAL HISTORY

Date of patient's last dental visit:

Has the patient ever had complications following dental treatment?

Yes

Does the patient currently have cavities/toothaches that need treatment?

Yes

Does the patient use any type of fluoride products?

Yes

Does the patient have any Clicking/ Popping or Jaw pain?

Yes

Inherited any family or dental problems?

Yes

Does the patient grind or clench teeth day or night?

Yes

Has the patient ever injured any teeth?

Yes

Has the patient ever injured jaws or face?

Yes

Sucked fingers or thumb?

Yes

Does the patient need to be pre-medicated before dental treatment?

Yes

Has the patient ever had tonsils/adenoids removed?

Yes

Please explain any item(s) selected "yes" from above:

Realizing that successful treatment greatly depends upon your cooperation in following instructions, keeping appointments, and maintaining oral hygiene. Are there any restrictions, handicaps, or problems that might be encountered during treatment? If so please describe them below:

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.

I authorize this office to verify my/my child's insurance benefit prior to my appointment.

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. *

I understand

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above. *

I understand

Signature Here *

Clear

What is your relationship to the patient:

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!