Child New Patient Form

Child Registration Form - Ortho
* required field

WELCOME - WE ARE LOOKING FORWARD TO HELPING YOU!

Patient Information

Sex
Date of Birth
Address
City


Home Telephone Number
School Attended
Hobbies
Whom may we thank for recommending our office?
Are there other children in your family?
If yes, please list names & ages
Fathers Full Name
Social Security Number
Date of Birth
Employed By
How Long?
Business Phone
Business Address
Position
Fathers Cell Phone
Fathers Address if different than patient
Mothers Full Name
Social Security Number
Date of Birth
Employed By
How Long?
Business Phone
Business Address
Position
Mothers Cell Phone
Mothers Address if different than patient
Email Address *
Parental Status

Who will provide the primary transportation for your child?
If different from parents, please list phone number here

Family Healthcare


Pediatrician/Others

Does the patient see a dentist every six months?

Do you understand that orthodontic patients need to see their regular dentist every 3-6 months during treatment for a dental checkup and cleaning?





Have you or other family members had orthodontic treatment?


Has your child had previous orthodontic treatment?




Is your child self conscious about the appearance of his/her teeth?


Is your child concerned about wearing braces, headgear, etc?


Does your child have a cooperative attitude?

Has your child ever been teased about the appearance of his or her teeth?

How many times a day does your child brush his teeth?

Do they floss?
Does tooth brushing occur with or without prompting?

Does your child enjoy sweets?


Mild to moderate dehydration can effect physical, mental, and physiological health and possibly effect the position of the developing teeth. In order to serve you better we would like you to approximate the fluids you consume daily, exclusive of those drinks that contain caffeine.




As much as we would like, we cannot possibly see all of our patients between 8 and 9 a.m. or between 3 and 5 p.m. Please help us by accepting a fair share of appointments during school and work hours. Are you willing to do this?

Medical History

Has your child ever been hospitalized or had any medical problems requiring long term medication or a blood transfusion?

Is your child under a doctor's care of taking any medication?

Has your child had rheumatic fever or other heart problems?

Does your child have any physical, mental, muscular or endocrine disorders?
Has your child or family member had any of the following infectious diseases?



If yes, is the disease still active?

Is your child allergic to any medication, foods, or anything else?

Are over-the-counter medications taken for allergy symptoms?

Has your child had any excessive bleeding requiring treatment or has had nose bleeds?

Have your child ever had an injury to the mouth, jaws, or head that resulted in jaw fracture or displacement head injuries requiring hospitalization, damage to the permanent teeth or swelling of the jaw joint?

Does your child have frequent headaches?
If yes

Is medication necessary?

Several oral habits can adversely affect the position of the teeth and the growth and development of the face. They include the following. If you have any of these habits, please check from the below list.







Does your child grind their teeth during the day or night?
Does your child breathe through their mouth?
If yes

Does your child snore at night?

Has your child had an adenoidectomy or tonsillectomy, tubes in their ears, or frequent infection of the tonsils?





Insurance Information

If you have insurance benefits for orthodontic care please fill out the following information completely. Also please provide a copy of the front and back of your insurance card. If you do not have a copy of your insurance card, please provide the following.







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