Skip to content
About Us
Meet Dr. Stoll
Meet The Team
Before and After
Areas Served
Broomfield
Thornton
Westminster
Treatments
Invisalign
How Invisalign Works
Invisalign For Teens
Invisalign For Adults
Smile Express
Braces
Braces for Teens
Braces For Adults
Early Treatment
Resources
Blog
Comfort Instructions
New Patient Info
Technology
Virtual Care
3D Printer
3D Scanner
X-Rays
Retainers for Life
Patient Portal
Contact Us
Menu
About Us
Meet Dr. Stoll
Meet The Team
Before and After
Areas Served
Broomfield
Thornton
Westminster
Treatments
Invisalign
How Invisalign Works
Invisalign For Teens
Invisalign For Adults
Smile Express
Braces
Braces for Teens
Braces For Adults
Early Treatment
Resources
Blog
Comfort Instructions
New Patient Info
Technology
Virtual Care
3D Printer
3D Scanner
X-Rays
Retainers for Life
Patient Portal
Contact Us
(303) 450-2211
New Child Patient Information Form
"
*
" indicates required fields
1
2
3
4
5
6
7
Patient Information
Is the patient a minor (under 18 years of age)?
*
Yes
No
Patient's Name
Gender
Male
Female
Social Security Number
Date of Birth
MM slash DD slash YYYY
Age
Home Address
City
State
Zipcode
Primary Phone Number
Primary Phone type
Home
Cell
Email Address
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Parent/Guardian Information
Marital Status
Single
Married
Divorced
Widowed
Significant Other
Relationship to Patient
Name
Social Security Number
Date of Birth
MM slash DD slash YYYY
Driver's License Number
Is your address the same as the patient's?
Yes
No
Home Address
City
State
Zipcode
Primary Phone Number
Phone Type
Home
Cell
Secondary Phone Number
Phone Type
Home
Cell
Other
Employer
Occupation
Add another parent / guardian?
Yes
No
Marital Status
Single
Married
Divorced
Widowed
Significant Other
Relationship to Patient
Name
Social Security Number
Date of Birth
MM slash DD slash YYYY
Driver's License Number
Is their address the same as the patient's?
Yes
No
Home Address
City
State
Zipcode
Primary Phone Number
Phone Type
Home
Cell
Secondary Phone Number
Phone Type
Home
Cell
Other
Employer
Occupation
Emergency Contact Information
Emergency Contact Name (other than parent)
Phone Number
Relationship to Patient
Address
City
State
Zipcode
Person(s) OK to release appointment or medically related information to concerning child:
Name
Relationship to Child
Add
Remove
Insurance Information
Do you have insurance?
Yes
No
Primary Insurance Information
Insurance Company
Phone Number
Group Number
Policy Number
Member ID
Policy Holder's Name
Relationship to Patient
Social Security Number
Date of Birth
MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Do you have secondary insurance?
Yes
No
Secondary Insurance Information
Insurance Company
Phone Number
Group Number
Policy Number
Member ID
Policy Holder's Name
Relationship to Patient
Social Security Number
Date of Birth
MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Dental History
General Dentist
Last Visit
How did you hear about our Practice?
Ad
Internet
Family / Friend
Physician
Other
Name of person referring (if applicable)
What are your main orthodontic concerns?
Has your child visited an orthodontist before?
Yes
No
When?
For What Reason?
Has your 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)?
None
Teeth
Mouth
Chin
Does your child have speech problems?
Yes
No
Please explain
Does your child currently or has your child ever had any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail biting
Thumb/ Finger Sucking
Chewing/Eating Problems
Medical History
Is your child currently being treated by a physician?
Yes
No
Reason(s)
Physician's Name
Phone Number
Does your child have any allergies/sensitivities to medications or latex?
Yes
No
If yes, please list allergies:
Is your child currently taking any prescription or over-the-counter medications?
Yes
No
If yes, please list medications and dosages:
Has puberty and/or menstruation begun?
Yes
No
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Has your child had any serious illnesses or operations?
Yes
No
If yes, please describe:
Has your child ever had a blood transfusion?
Yes
No
If yes, give approximate date(s):
Is your child pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
Does your child have, or have they ever had, any of the following? (check all that apply)
None of these
Abnormal Bleeding
Anemia
Arthritis, Rheumatism
Artificial Heart Valve
Artificial Joints
Asthma
Back Problems
Blood Disease
Blood Transfusion
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Defect
Cortisone Treatments
Cough, persistent
Coughing Blood
Diabetes
Difficulty Breathing
Drug/Alcohol Abuse
Epilepsy
Emphysema
Fainting
Fever Blisters/Herpes
Glaucoma
Headaches
Heart Attack
Heart Surgery
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
High/Low Blood Sugar
HIV/AIDS
Hospitalized for Any Reason
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shingles
Shortness of Breath
Sickle Cell Disease/Traits
Sinus Problems
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Authorization
Consent
*
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 medical status. I hereby authorize the release of any information pertaining to my 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.
*
Signature of Parent / Guardian or Responsible Party
*
Date
*
MM slash DD slash YYYY
