Step 1 of 9 11% 1. Tell Us About Your ChildChild's Name* First Last Nickname Gender* Male Female Child's Birthdate* MM slash DD slash YYYY Child's Age* School Grade Hobbies/Sports Email* Child's Cell #Child's Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2. Who is Accompanying Your Child Today?Name* First Last Relation* Do you have legal custody of this child?* Yes No Whom may we thank for referring you? List brothers/sisters with age General Dentist: Last Visit Date MM slash DD slash YYYY Parent's Martial Status Single Marries Divorced Widowed Other 03. Mother's InformationRelationship to Patient Biological Mother Stepmother Guardian Name* First Last Birthdate* MM slash DD slash YYYY Work PhoneHome Phone*Employer How long there? Job Title SSL#* Drivers License #* 04. Father's InformationRelationship to Patient* Biological Father Stepfather Guardian Name* First Last Birthdate* MM slash DD slash YYYY Home PhoneWork PhoneEmployer How long there? Job Title Social Security #* Driver's License Number* 5. Person Responsible For AccountName* First Last Relation* Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Driver's License # Employer Work PhoneSocial Security #* Name of Person Responsible for Appointments* First Last Work Phone 6. Dental / Orthodontic InsuranceOrthodontic Coverage* Yes No Insurance Co. Name: Insurance Co. Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Co. PhoneSubscriber ID# Policy Owner's Name: Relationship to Patient: Policy Owner's Birthdate: MM slash DD slash YYYY Social Security # Policy Owner's Employer: 7. What are the main concerns that you would like orthodontics to accomplish?Has your child ever been evaluated or had orthodontic treatment before?* Yes No Have there been any injuries to the face, mouth, teeth or chin?* Yes No Please explain:* List any musical instruments played: Have adenoids or tonsils been removed?* Yes No Has your child been informed of any missing or extra permanent teeth?* Yes No Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?* Yes No Does your child brush his/her teeth daily?* Yes No Floss his/her teeth daily?* Yes No Child's Physician* Child's Physician Phone*Is your child currently under the care of a physician?* Yes No Has puberty begun?* Yes No Has menstruation begun? (Girls) Yes No Please describe your child's current physical health:* Good Fair Poor Please list all drugs that your child is currently taking:* Please list all drugs that your child is allergic to: 8. Has your child ever had any of the following medical problems?Abnormal Bleeding* Yes No Allergies to Any Drugs* Yes No Allergies to Latex/Metals* Yes No Allergies to Plastic* Yes No Any Hospital Stays* Yes No Any Operations* Yes No Asthma* Yes No Bruxism/Grinding* Yes No Cancer* Yes No Clenching* Yes No Congenital Heart Defect* Yes No Convulsions/Epilepsy* Yes No Diabetes* Yes No Handicaps/Disabilities* Yes No Head and Neck Pain* Yes No Headaches* Yes No Hearing Impairment* Yes No Heart Murmur* Yes No Hemophilia* Yes No Hepatitis* Yes No HIV+/ AIDS* Yes No Keloids* Yes No Kidney/Liver Problems* Yes No Rheumatic/Scarlet Fever* Yes No Sleep Apnea* Yes No Snoring* Yes No TMJ Pain* Yes No Tuberculosis(TB)* Yes No ADD/ADHD/Aspergers* Yes No Please discuss any medical problems that your child has had: 9. Does/did your child have any of the following habits?Clenching/Grinding Teeth* Yes No Lip Sucking/Biting* Yes No Mouth Breather* Yes No Nail Biting* Yes No Nursing Bottle Habits* Yes No Speech Problems* Yes No Thumb/Finger Sucking* Yes No Tongue Thrust* Yes No I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.Signature of parent or guardian (Sign with Mouse)* Reset signature Signature locked. Reset to sign again Patient Signature (Sign with Mouse)* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY
973-408-9183
631-248-2400
Virtual Exam
973-408-9183
631-248-2400
Virtual Exam