PATIENT INFORMATION


Child's Name Last
First
Middle

Address
Street

City
State
Zip

Phone Birth date S.S.N. E-mail address

School Grade

Siblings     (Names and ages please)
If patient is a minor, give parent's or guardian's name.
Whom can we thank for referring you to our office?

RESPONSIBLE PARTY INFORMATION


Name Marital Status

Last
First
Middle
Residence
Street

City
State
Zip
Mailing Address
Street

City
State
Zip
Home Phone Work Phone Cell Phone
Social Security # Birth date Relationship to Patient

Employer Occupation

Spouse's Name  Relationship to Patient

Last
First
Middle

Employer Occupation  
 
Social Security # Birth Date Work Phone

INSURANCE INFORMATION


Insured's Name Insured's Social Security #
Insured's Employer

Insurance Company Group Number Local Number

Insurance Company Address
Insurance Phone Number

MEDICAL HISTORY


Your Child's Physician
Phone Number
Date of Last Visit

YES NO     YES NO  
Is your child taking any medication?
If yes, please specify:
 Has your child had any major operations?
Is your child allergic to any medications?
If yes, please specify:
 Has your child ever been involved in a serious accident?
Does your child have a history of a major illness?
If yes, please specify:
      
Have your child ever had any of the following diseases or medical problems
YES NO     YES NO  
Abnormal Bleeding / Hemophilia Hepatitis / Liver Problems
Anemia Herpes
Arthritis High Blood Pressure
Asthma or Hayfever HIV + / AIDS
Bone Disorders Kidney Problems
Congenital Heart Defect Nervous Disorders
Diabetes Pneumonia
Dizziness Prolonged Bleeding
Epilepsy Radiation / Chemotherapy
Gastrointestinal Disorders Rheumatic Fever
Heart Problems Tuberculosis
Heart Murmur Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?

PATIENT DENTAL HISTORY


Child's Dentist
Date of Last Visit
Dentist Phone Number
What Concerns you most about your child's teeth?

  YES NO
Is your child presently in any dental pain?
Has your child ever experienced any unfavorable reaction to dentistry?
Has your child ever lost or chipped any teeth?
Has your child had any injuries to face, mouth or teeth?
Is any part of your child's mouth sensitive to temperature or pressure?
Do your child's gums bleed when they brush?
Does your child have any type of thumb or tongue habit?
Is your child a mouth breather?
Has your child ever seen an orthodontist?
Has anyone in the family received orthodontic treatment?
How did they feel about the result ?
What is your child's attitude toward orthodontic treatment ?
Does your child's teeth or jaws ever feel uncomfortable when they awake in the morning?
Is your child aware of their jaw clicking or popping?
Is your child aware of clenching their teeth during the day?
Has your child ever been told that they grind their teeth?
Does your child have "tension" headaches?
Has your child ever experienced chronic ringing in their ears ?
Are you aware some appointments will be during school hours?
     
Please list any additional concerns or comments:

GROWTH AND DEVELOPMENT HISTORY

Has the patient had any recent rapid growth?
If yes, what?
Has the patient reached puberty?
Females: When? (month & year)

I hereby authorize payment of the group insurance benefits(otherwise payable to me) directly to this office. I understand that I am responsible for all costs for orthodontic treatment whether or not paid by insurance. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company. I authorize the use of this signature on all insurance submissions, whether filed manually or electronically. 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 confidence and that it is my responsibility to inform this office of any changes in my or my child's medical status. I authorize the dental staff to perform any necessary dental services that I, or my child, may need during diagnosis and treatment, with my informed consent. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment. I further agree to pay all finance charges, collection costs, attorney's fees and any other cost that may be incurred to enforce collection of any outstanding balance and authorize credit bureau reports to be obtained for collection purposes.

Initials of Patient(if over 18) or Legal Guardian | Date: 7/30/2010