Child Patient Form

Child Form

  • Patient Info


  • Patient Name
  • How did you hear about Black Orthodontics?

    (Please supply a name so we can thank them.)

  • RESPONSIBLE PARTY INFORMATION


  • RESPONSIBLE PARTY 2 INFORMATION


  • EMERGENCY CONTACT INFORMATION


  • ORTHODONTIC INSURANCE INFORMATION


    If the patient is covered under Medicaid please complete all information.
  • PATIENT'S DENTAL INFORMATION


  • MEDICAL INFORMATION


  • Has your child ever had any of the following diseases or medical problems?


  • PATIENT DENTAL HISTORY


  • GROWTH AND DEVELOPMENT HISTORY



  • 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.