Child New Patient Information

Child Registration Form - Medical

Patient Information

Male Female






Primary Phone Number
HomeCell





Parent/Guardian Information

Parents' Marital Status Single Married Divorced Widowed Significant Other







Phone Number
HomeCell
Secondary Phone Number
HomeCell








Phone
HomeCell
Secondary Phone Number
HomeCell


Emergency Contact









Insurance Information


























Dental History


How did you hear about our Practice? Ad Internet Family or Friend Physician Other
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? Yes No
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No
Does your child you have any missing or extra permanent teeth? Yes No
Has your child ever had an injury to (select all that apply): Teeth Mouth Chin
Does your child have speech problems? Yes No
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? Yes No



Does your child have any allergies/sensitivities to medications or latex? Yes No
Is your child currently taking any prescription or over-the-counter medications? Yes No
Has puberty and/or menstruation begun? Yes No N/A
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)? Yes No
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion? Yes No


Check if your child has or have 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.




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