Child New Patient "*" indicates required fields 1234567 Patient InformationIs 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 NumberPrimary Phone type Home Cell Email Address School Grade List any sports or extracurricular activities Siblings (names and ages) Parent/Guardian InformationMarital 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 NumberPhone Type Home Cell Secondary Phone NumberPhone 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 NumberPhone Type Home Cell Secondary Phone NumberPhone Type Home Cell Other Employer Occupation Emergency Contact InformationEmergency Contact Name (other than parent) Phone NumberRelationship to Patient Address City State Zipcode Person(s) OK to release appointment or medically related information to concerning child:NameRelationship to Child Add Remove Insurance InformationDo you have insurance? Yes No Primary Insurance InformationInsurance 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 NumberCo-pay (if known) Deductible (if known) Do you have secondary insurance? Yes No Secondary Insurance InformationInsurance 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 NumberCo-pay (if known) Deductible (if known) Dental HistoryGeneral 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 explainDoes 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 HistoryIs your child currently being treated by a physician? Yes No Reason(s) Physician's Name Phone NumberDoes 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 AuthorizationConsent* 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
