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888.339.8108

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Call Us

888.339.8108

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Child

Request an Appointment
Gender:
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Phone Type
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Parent / Guardian Information

Parent 1

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

Parent 2

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

Emergency Contact Information

Insurance Information

Primary Insurance

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Secondary Insurance

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Dental History

How did you hear about our practice?
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?
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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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