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to the Orthodontist The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral health. Please fill out this form completely. The better we communicate, the better we can care for you! 1. Tell Us About Your Child Today’s Date: Child’s Name: Nickname: Male School: Female Birthdate: Grade: Age: Child’s Home #: ( Hobbies/Sports: SS#: ) E-mail Address: Childs Home Address: 2. Parental Information Mother Name: Stepmother Guardian Birthdate: Employer: Work #: ( _) Job Title: SS#: Home #: ( ) How long have you been there? DL#: Father Name: Stepfather Guardian Birthdate: Employer: Work #: ( _) Job Title: SS#: Home #: ( ) How long have you been there? DL#: Who is Accompanying your Child today? Person responsible for Account: Relation: Who referred you? 3. Primary Orthodontic Insurance Orthodontic Coverage? Yes No Insurance Co. Name: Insurance Co. Phone #: ( ) Policy Owner’s Name: Relationship to Patient: Policy Owner’s Birthdate: SSN#: Please give your Insurance card to the receptionist for a copy, thank you! 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 confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that my child may need during diagnosis and treatment. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services. I will accept responsibility for any bill incurred for Orthodontic treatment. Signature _____________________ Date: ___________ 4. Patient’s Health History Patient Dentist: Phone #: ( ) Has the patient had previous orthodontic consultations? Last Cleaning: Yes No Treatment? Yes No If so please list where: Present Drugs/Medications: List any allergies or drug sensitivity: What are the main concerns that you would like orthodontics to accomplish? Has your child ever taken Phen-Fen? Yes No (Redux or Pondimin) If yes, When? Have there been any injuries to the face, mouth, teeth or chin? List any musical instruments played: Yes No Have adenoids or tonsils been removed? Yes No Has your child been informed of any missing or extra permanent teeth? Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)? Does your child brush his/her teeth daily? Yes No Is your child under the care of a physician? Please describe your child’s current physical health: Good Have you ever had any of the following Diseases/ Medical problems: Abnormal Bleeding/Hemophilia ADD/ ADHD Allergies to Any drugs Allergic to Latex / Metals Allergic to Plastic Any hospital stays Any operations Artificial Bones/Joints /Valves Asthma Cancer Congenital Heart Defect Tuberculosis (TB) Yes No Phone #: ( ) Date of last visit: Yes No No Does your child floss his/her teeth daily? Child’s Physician: 5. Yes Yes No Convulsions / Epilepsy Diabetes Handicaps / Disabilities Hearing Impairment Heart Murmur Hemophilia Hepatitis HIV + / AIDS Kidney / Liver Problems Lupus Rheumatic/Scarlet Fever Please list any serious medical condition(s) that you have ever had: Fair 6. Yes No Yes No Poor Has your child ever experienced any of the following? Clenching / Grinding Teeth Lip Sucking / Biting Mouth breather Nail Biting Yes No Nursing/ Bottle Habits Speech Problems Thumb / Finger sucking Tongue Thrust Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and ADA. Neighbor or Relative not living with you: Name: Phone #: ( ) Address: Thank you for visiting the office of Dr. Guajardo it was a pleasure seeing you and your child and we look forward to seeing you again!