Stoll Orthodontics | Thornton CO

Child New Patient

    Patient Information

    Is the patient a minor (under 18 years of age)?
    You have indicated that the patient is NOT a minor (under the age of 18). Please complete our Adult New Patient Form.
    Patient's Name
    Gender
    MaleFemale

    Birth Date

    Primary Phone Number

    Primary Phone type
    HomeCell

    Parent/Guardian Information

    Parent Marital Status
    SingleMarriedDivorcedWidowedSignificant Other
    Relationship

    Birth Date

    Primary Phone Number

    Phone type
    HomeCell
    Secondary Phone Number

    Phone type
    HomeCellOther

    Relationship

    Birth Date

    Primary Phone Number

    Phone type
    HomeCell
    Secondary Phone Number

    Phone type
    HomeCellOther

    Emergency Contact Information

    Insurance Information

    Primary Insurance Company













    Secondary Insurance Company













    Dental History


    How did you hear about our Practice?
    AdInternetFamily or FriendPhysicianOther

    Has your child visited an orthodontist before?
    YesNo

    Has your child's tonsils or adenoids been removed?
    YesNo
    Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
    YesNo
    Does your child have any missing or extra permanent teeth?
    YesNo
    Has your child ever had an injury to (select all that apply)?
    noneTeethMouthChin
    Does your child have speech problems?
    YesNo
    Does your child currently or has your child ever had any of the following habits?
    Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems

    Medical History

    Is your child currently being treated by a physician?
    YesNo



    Does your child have any allergies/sensitivities to medications or latex?
    YesNo
    Is your child currently taking any prescription or over-the-counter medications?
    YesNo
    Has puberty and/or menstruation begun?
    YesNoN/A
    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)?
    YesNo
    Has your child had any serious illnesses or operations?
    YesNo
    Has your child ever had a blood transfusion?
    YesNo
    Is your child pregnant?
    YesNo
    Nursing?
    YesNo
    Taking birth control pills?
    YesNo
    Check if your child has or have ever had any of the following:
    Abnormal BleedingAnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseBlood TransfusionCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart DefectCortisone TreatmentsCough, PersistentCoughing BloodDiabetesDifficulty BreathingDrug/Alcohol/AbuseEpilepsyEmphysemaFaintingFever Blisters/HerpesGlaucomaHeadachesHeart AttackHeart SurgeryHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHigh/Low Blood SugarHIV/AIDSHospitalized for Any ReasonJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShinglesShortness of BreathSickle Cell Disease/TraitsSinus ProblemsSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

    Authorization



    Date