Child Patient Form

Experienced, friendly and dedicated dental health professionals

Preferred Name:

Male Female Non-binary

Social Security Number: Birth Date: Age:
Home Address: City: State: Zip:

Primary Phone Number: home cell Ok to leave message? Yes No

School: Grade:
List any sports or extracurricular activities:
Siblings (names and ages):

Parents' Marital Status Single Married Divorced Widowed Significant Other / Partner

Parent1 Parent2 Step Parent Guardian Other

Male Female Non-binary

Name: Social Security Number: Birth Date: E-mail Address:
Address (if different than child's): City: State: Zip:

Phone Number: home cell work

Secondary Phone Number: home cell work

Employer's Name: Occupation:

Parent1 Parent2 Step Parent Guardian Other

Male Female Non-binary

Name: Social Security Number: Birth Date: E-mail Address: Address (if different than child's): City: State: Zip:

Phone Number: home cell work

Secondary Phone Number: home cell work

Employer's Name: Occupation:

Emergency Contact Name (other than parent): Phone Number: Relation to child: Address: City: State: Zip:

Person(s) OK to release appointment or medically related information to concerning child: Relation(s) to child:

Primary Dental Insurance Company: Phone Number: Group/Policy Number: Member ID#: Member/Subscriber Name: Relation: Policy Holder's Social Security Number: Policy Holder's Date of Birth:
Employer: Phone Number:

Secondary Dental Insurance Company: Phone Number: Group/Policy Number: Member ID#: Policy Holder's Name: Relation: Policy Holder's Social Security Number: Policy Holder's Date of Birth:
Employer: Phone Number:

General Dentist: Last Visit:

How did you hear about our Practice? Ad Internet Family/Friend Physician Other
Name of person referring (if applicable) :

Has your child visited an orthodontist before? Yes No
When: Reason:

Have we treated any other family members? Yes No
Name:

Have your child's tonsils or adenoids been removed? Yes No

Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)? Yes No

Does your child have any missing or extra permanent teeth? Yes No

Has your child ever had an injury to (select all that apply): Teeth Mouth Chin

Does your child have speech problems? Yes No
If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply)? Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

Is your child currently being treated by a physician? Yes No
Reason: Physician: Last Visit: Phone:

Does your child have any allergies/sensitivities to medications or latex? Yes No
If yes, please list:

Is your child currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Has puberty and/or menstruation begun? Yes No NA

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: