Patient Information * Patient Name: (Required)
Social Security Number: Birth Date: Age: Home Address: City: State: Zip: Primary Phone Number: * E-mail: (Required) School: Grade: List any sports or extracurricular activities: Siblings (names and ages): Parent / Guardian Information Parents' Marital Status
Name: Social Security Number: Birth Date: Driver License Number: Address (if different than child's): City: State: Zip: Phone Number: Secondary Phone Number: Employer's Name: Occupation:
Name: Social Security Number: Birth Date: Driver License Number: Address (if different than child's): City: State: Zip: Phone Number: Secondary Phone Number: Employer's Name: Occupation: Emergency Contact Information Emergency Contact Name (other than parent): Phone Number: Relation to child: Address: City: State: Zip:
Person(s) OK to release appointment or medically related information to concerning child: Relation(s) to child: Insurance Information Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Co-pay (if known): Deductible (if known):
Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Co-pay (if known): Deductible (if known):
Dental History General Dentist: Last Visit: How did you hear about our Practice? Name of person referring (if applicable) : What are the main concerns you would like orthodontics to accomplish? Concerns: Has your child visited an orthodontist before? When: Reason: Have we treated any other family members? Name: Have your child's tonsils or adenoids been removed? Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)? Does your child 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? If so, explain: Does your child currently or has your child ever had any of the following habits (check all that apply): Medical History Is your child currently being treated by a physician? Reason: Physician: Last Visit: Phone: Does your child have any allergies/sensitivities to medications or latex? If yes, please list: Is your child currently taking any prescription or over-the-counter medications? Please list, with dosage: 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 had any serious illnesses or operations? If yes, describe: Has your child ever had a blood transfusion? If yes, give approximate dates: Is your child pregnant? Nursing? Taking birth control pills? Check if you have ever had any of the following: 