Child Patient Form
Contact Us
Phone: 8282777103
E-mail: info@www.kblacksmiles.com
5 Yorkshire St | Suite A
Asheville, NC 28803
Phone: 8282777103
E-mail: info@www.kblacksmiles.com
5 Yorkshire St | Suite A
Asheville, NC 28803
At Black Orthodontics, we want to offer a special plan just for you. Can you help us by answering the following questions? Please answer and check all that apply. |
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Childs Name | Last * |
First * |
Middle |
Address | Street |
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City |
State |
Zip |
Phone |
Birth date |
S.S.N. |
E-mail address |
School |
Grade |
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Siblings (Names and ages please) |
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If patient is a minor, give parent’s or guardian’s name. |
What treatment options are you most interested in? | What payment options would be best for you? | ||
Damon Damon Clear Braces Traditional Braces |
Teen Invisalign Invisalign Early Treatment |
Payment in Full with Special Discount No Down Payment Plan – No Interest Affordable Monthly Payments – No Interest Flexible Spending Account |
Chase/Care Credit Extended Payment Plan w/ Interest In-house Financing – No Interest |
Does the patient/responsible party blog? Yes No |
What social Networks are they apart of? Please list them below! ie. Facebook, Twitter etc. |
Name | Marital Status | ||
Last * |
First * |
Middle |
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Residence | Street |
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City |
State |
Zip |
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Mailing Address | Street |
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City |
State |
Zip |
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Home Phone * |
Work Phone * |
Cell Phone * |
E-mail Address * |
What is the best contact number? |
Birth Date |
S.S.N |
Relationship to Patient |
Employer |
Occupation |
Responsible Party 2 Name | |||
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Last |
First |
Middle |
Relationship to Patient |
S.S.N |
Birth Date |
Work Phone |
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Employer |
Occupation |
Contact Name |
Phone |
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Address | Street |
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City |
State |
Zip |
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Relationship to patient |
Insured’s Name |
Insured’s S.S.N. |
Insured’s Employer |
Insurance Company |
Group Number |
Local Number |
Insurance Company Address |
Insurance ID # |
Insurance Phone Number |
Child’s Dentist |
Date of Last Visit |
Dentist Phone Number |
Your Child’s Physician |
Phone Number |
Date of Last Visit |
YES | NO | YES | NO | |||
Is our 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 |
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Has 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? |
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 you awake in the morning? | ||
Is your child aware of their jaw clicking or popping? | ||
Is your child aware of clenching your teeth during the day? | ||
Has your child ever been told that they grind your 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 / work hours? | ||
Please list any additional concerns or comments:
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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 May 16, 2012 |
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