Child Patient Information Form

Child Patient Information Form
MINOR PATIENT INFORMATION
Whom may we thank for referring you to our office?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Name

First NameLast Name
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Identifies As
Reason for Visit:
Parent/Legal Guardian Responsible for Appointments
Legal Guardian

First NameLast Name
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Legal Guardian
Legal Guardian

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
INSURANCE INFORMATION
Insured's Name

First NameLast Name
Insurance Company
Member ID # / Subscriber #
DOB of Subscriber

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Group #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Do you have dual coverage?
Insured's Name

First NameLast Name
Insurance Company
Subscriber #
Group #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
GENERAL INFORMATION
Number of Children in Family:
Name(s) of any family member(s) in treatment or previously with us:
Name of Previous Orthodontist:
General Dentist's Name
General Dentist's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Dental Check-Up

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is the patient currently under treatment?
Physician's Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the patient currently under treatment?
ANY HISTORY OF:
Thumb or finger sucking?
If yes, until what age?
Grinding of teeth?
If yes, when?
Frequent headaches or jaw pain?
Difficulty eating any foods?
Speech difficulty or speech therapy?
MEDICAL HISTORY
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Are you in general good health at this time?
Are you under any medical treatment now?
Are you taking any drugs or medications?
If yes, please list:
Have you ever had any adverse response to any drugs, including penicillin?
If yes, please list:
Is the patient allergic to any known materials/foods resulting in hives, asthma, eczema, or anaphylaxis?
If yes, please list:
Has the patient ever had any major operations including hip/joint replacement?
If yes, please specify:
Are you allergic to latex?
Have you ever had any radiation therapy or chemotherapy?
Have you ever had a serious accident involving head injuries?
Have you had a history of any of the following?

Other
Do you snore?
Do you have a history of fainting?
Are you pregnant?
DENTAL HISTORY
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Have you ever had gum disease, or periodontal treatment?
Do you frequently get sore spots in your mouth?
Do you have any dental complaints at the present time?
Do you have a history of back or neck injuries? Whiplash?
Do you have any clicking or popping of your jaw (TMJ)?
Do you habitually clench or grind your teeth during the night or day?
Do you chew on only one side of your mouth?
If so, why?
Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc.)?
If so, where?
Have you ever taken medication for treatment of Osteoporosis?
PATIENT MEDICAL/DENTAL HISTORY
In case of an emergency, contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PURPOSE OF CONSENT (HIPAA)
By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.
Signature of Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Child Patient Information Form

MINOR PATIENT INFORMATION

Parent/Legal Guardian Responsible for Appointments

Parent/Legal Guardian

INSURANCE INFORMATION

GENERAL INFORMATION

ANY HISTORY OF:

MEDICAL HISTORY

DENTAL HISTORY

PATIENT MEDICAL/DENTAL HISTORY

PURPOSE OF CONSENT (HIPAA)