Child Form

IslandBraces.com Child Registration Form

Patient Information

Gender:
*
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Phone Type
* OK to leave message? (Required)
* OK to Text? (Required)
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Parent / Guardian Information

Responsible Party 1

Marital Status
Relation to Child:
Phone Type:
Phone Type:

Responsible Party 2

Marital Status
Relation to Child:: Mother
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

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How did you hear about our practice?
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Has your child visited an orthodontist before?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

Is your child currently being treated by a physician?
Do you have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever had a blood transfusion?
Check if your child has or has 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 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.

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Vicki Wang Orthodontics

  • Vicki Wang Orthodontics - 1740 Santa Clara Ave., Alameda, CA 94501 Phone: 510-522-4462

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