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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: _______________________