• Child Patient Form

    Child Patient Form

  • CHILD INFORMATION

  • Birthdate:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:*
  •  -

  • WHO IS ACCOMPANYING YOUR CHILD TO THE APPOINTMENT?

  • Do you have legal custody of this child?
  • Parent’s Marital Status:*

  • PARENT #1 INFORMATION

  • Birthdate:*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -
  •  -

  • PARENT #2 INFORMATION

  • Birthdate:
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -
  •  -

  • PERSON RESPONSIBLE FOR ACCOUNT

  • Relation:*
  •  -

  • PRIMARY DENTAL INSURANCE

  • Do you have dental coverage?*
  •  -
  • Insured's Birthdate:
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECONDARY DENTAL INSURANCE

  • Do you have secondary dental coverage?
  •  -
  • Insured's Birthdate:
     - -
    2 digit month, 2 digit day, 4 digit year

  • DENTAL/MEDICAL HISTORY

  • Has your child ever had or been evaluated for or had orthodontic treatment before?*
  • Have there been any injuries to the Face, mouth, teeth or chin?*
  • Have the adenoids or tonsils been removed?*
  • Has your child been informed of any missing or extra permanent teeth?*
  • Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?*
  • Does your child brush his / her teeth daily?*
  • Floss his / her teeth daily?*
  •  -
  • Date Of Last Visit:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please describe your child’s physical health:*
  • Has puberty begun:*
  • Has menstration begun (girls):
  • Allergic to latex?*
  • Allergic to metals/nickel?*
  • Allergic to plastics?*
  • Has your child ever had any of the following medical problems?*
  • Has your child ever experienced any of the following?*

  • Thank you for filling out this form completely.

  • 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 confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

    This office reserves the right to verify the credit status of potential patients
    and / or parents of patients prior to extending credit for treatment fees and
    may, at the discretion of the office, use the services of one or more credit
    reporting services.

    I authorize the dental staff to perform any necessary dental services my child may need.

  • Date Submitted:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Privacy Practice

  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

    • To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
    • To third-party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
    • To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
    • Internally, to all staff members who have any role in your treatment;
    • To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
    • To your family and close friends involved in your treatment; and/or
    • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

    Under the new privacy rules, you have the right to:

    • Request restrictions on the use and disclosure of your protected health information;
    • Request confidential communication of your protected health information;
    • Inspect and obtain copies of your protected health information through asking us;
    • Amend or modify your protected health information in certain circumstances;
    • Receive an accounting of certain disclosures made by us of your protected health information; and,
    • You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

    We have the following duties under the privacy rules:

    • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
    • To abide by the terms of our Privacy Notice that is currently in effect; and,
    • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

    Please note that we are not obligated to:

    • Amend your protected health information if, for example, it is accurate and complete; or,
    • Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

    This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.

    I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

    Privacy Policy for SMS messages

    We, Johnson Orthodontics, respect your privacy and are committed to protecting your personal information.  This Privacy Policy explains how we collect, use, and share information when you opt in to receive SMS messages from us.

    Information We Collect

    When you opt in to receive SMS messages, we collect:

    • Your phone number
    • Consent to send SMS messages

    How We Use Your Information

    We use your information to:

    • Send you the SMS messages you’ve opted in to receive
    • Provide updates, promotions, or other relevant content based on your preferences
    • Consumer information is not shared with third-parties for marketing purposes.

    Sharing Your Information

    We do not share your phone number or SMS opt-in information with third parties for marketing purposes.

    Your Rights

    You can opt out of receiving SMS messages at any time by replying with “STOP” to any message we send you.

    Data Security

    We implement reasonable measures to protect your personal information from unauthorized access or disclosure.

    If you have questions or concerns about our privacy practices, contact us at 302-645-5554.

  • Date Submitted*
     - -
    2 digit month, 2 digit day, 4 digit year

  • ORTHODONTIC APPOINTMENT PERMISSION

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • We know your schedule is busy and it’s not always convenient to accompany your child to every appointment. Whether your child is brought in by Grandma, another family member or a friend, or is old enough to drive themselves, we want to make getting to their orthodontic appointments as easy as possible for your family. By signing below, you're giving Johnson Orthodontics permission to see your child for their regularly scheduled orthodontic appointments, even when you aren't here.

  • What does this mean?

    • We can complete routine orthodontic adjustments and other visits that are already part of your child's treatment plan.
    • We'll keep you in the loop! Appointment summaries, instructions and recommendations will be shared with you by text or email.
    • You're still in charge of the big decisions. This permission does not authorize changes to your child's treatment plan or other major treatment decisions.
  • Please check one*
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • This permission remains in effect until I withdraw it in writing, my child turns 18, or active orthodontic treatment is completed, whichever comes first.
  • Should be Empty: