Child Form

Patient Information

* Patient Name: (Required)

Gender: Male Female Non-Binary

* Birth Date: (Required)

Age:

Home Address:

City:

State:

Zip:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Responsible Party 1

Name:

Birth Date:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer's Name:

Occupation:

Responsible Party 2

Name:

Birth Date:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer's Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

* General Dentist: (Required)

Last Visit:

How did you hear about our practice? Internet Family/Friend Physician Other

Name of person referring (if applicable):

* What are the main concerns you would like orthodontics to correct? (Required)

Has your child visited an orthodontist before? Yes No

If yes, when?: Reason:

Have we treated any other family members? Yes No

Name:

Medical History

Is your child currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Has puberty and/or menstruation begun? Yes No NA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion? Yes No

If yes, give approximate dates:

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 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: (Required)

Date: