Download NEW PATIENT FORM - CHILD Patient Information Patient Name

NEW PATIENT FORM - CHILD
Patient Information
Patient Name:
Male Female
Home Address:
City:
State:
Zip:
Primary Phone Number:
home cell
Email:
Sports/Extracurricular Activities/Hobbies:
Siblings: (first name, age)
Birth Date:
Parent/Responsible Party Information
Mother Step-mother Guardian
Other
Name: _______________
Parent’ Marital Status: Single Married Divorced Widowed Significant Other
Birthday: _______
Social Security Number: _______
Address (if different than child’s): ____________________
City: ____________________
State:______
Zip code:_______________
Phone number:________ home cell
Employer’s Name:__________________
Occupation: ________________
Father Step-father Guardian Other
Name: _______________
Birthday:_______
Social Security Number: _______
Address (if different than child’s):___________________
City: ___________________
State: ______
Zip code: ______________
Phone number: _________ home cell
Employer’s Name: ___________________
Occupation:________________
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 concerning child:
________________________________________________________________________
Dental Insurance Information
Primary Insurance Company: ______________________
Group Number: ______________
Policy/Subscriber/Member ID: _______________
Subscriber’s Name: __________________
Subscriber’s Social Security number: __________
Subscriber’s Date of Birth: ______________
Subscriber’s Employer: _______________
Provider Services Phone number: ___________
Secondary Insurance Company: ______________________
Group Number: ____________
Policy/Subscriber/Member ID: _______________
Subscriber’s Name: __________________
Subscriber’s Social Security number: __________
Subscriber’s Date of Birth: ______________
Subscriber’s Employer: _______________
Provider Services Phone number: ___________
General Dentist: ____________________________
Last Visit: ___________________
Whom may we thank for referring you to our office? _______________________________
Family/Friend Doctor Ad Internet Search Insurance
Has your child visited an orthodontist before? Yes No
When: _________________ Reason: __________________
Have we treated any other family members? Yes No
Health History
Have you 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 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
If so, explain:
Does your child currently or has your child ever had any of the following habits (check all that apply)?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem
Is your child currently being treated by a physician? Yes No
Reason: ____________ Physician: ___________ Last Visit: __________
Phone: _______________________
Does your child have any allergies/sensitivities to medications or latex? Yes No
If yes, please list:
Is your child currently taking any prescription or overthecounter medications? Yes No
Please list, with dosage: _________________________________________
Has puberty and/or menstruation begun? Yes No N/A
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 child's medical status.
I hereby authorize the release of any information pertaining to my child's 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.
Submitted by:______________________ Date: _______________________