Child Patient Form Patient Information Patient Name You are MaleFemale Birth Date Age Home address City Province Postal code Primary Phone number Email School Grade List of any sports and other activities Siblings (name and age) Parent and Guardian Information Parent Marital Status SingleMarriedDivorcedWidowedSignificant Other Select One MotherStep MotherGuardianOther Name Date of birth address(if different than child's) City Province Postal Code Primary Phone number Secondary Phone number Employer's name Occupation Postal Code FatherStep FatherGuardianOther Name Date of birth address(if different than child's) City Province Postal Code Primary Phone number Secondary Phone number Employer Name Occupation Emergency contact number emergency contact name Phone number Related to child Address City Province Postal Code Person(s) OK to release appointment or medically related information to concerning child Related to child Insurance Information Do you have insurance that covers orthodontics? YesNo Dental History General dentist Last visit How did you hear about our Practice? ADInternetFamily/FriendDentistOther Name of the person referring What are the main concern you would like orthodontics to accomplish ? Has your child visited an orthodontist before? YesNo When ? Why ? Have we treated any other family members? YesNo Name ? Have 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) TeethMouthChin Does your child have speech problems? YesNo If so explain ? Does your child currently or has your child ever had any of the following habits (check all that apply)? Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating Problem Medical History Is your child currently being treated by a physician? YesNo Reason Physician Last Visit Phone Does your child have any allergies/sensitivities to medications or latex? YesNo If yes, please list ? Is your child currently taking any prescription or over-the-counter medications? YesNo please list, with dosage Has your child had any serious illnesses or operations? If yes, describe: Write here Has your child ever had a blood transfusion? YesNo If yes, give approx date Is your child pregnant? YesNo Nursing ? YesNo Taking birth control pills ? YesNo Check if your child has or has ever had any of the following ? AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsilitisTuberculosisUlcerVenereal Disease (STD) I understand that 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 of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. Submitted by Date
