Step 1 of 9 11% 1. Tell Us About Your ChildChild's Name* First Last NicknameGender*MaleFemaleChild's Birthdate* Date Format: MM slash DD slash YYYY Child's Age*SchoolGradeHobbies/SportsEmail* Child's Cell #Child's Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?*YesNoWhom may we thank for referring you?List brothers/sisters with ageGeneral Dentist:Last Visit Date Date Format: MM slash DD slash YYYY Parent's Martial StatusSingleMarriesDivorcedWidowedOther 03. Mother's InformationRelationship to PatientBiological MotherStepmotherGuardianName* First Last Birthdate* Date Format: MM slash DD slash YYYY Work PhoneHome Phone*EmployerHow long there?Job TitleSSL#*Drivers License #* 04. Father's InformationRelationship to Patient*Biological FatherStepfatherGuardianName* First Last Birthdate* Date Format: MM slash DD slash YYYY Home PhoneWork PhoneEmployerHow long there?Job TitleSocial Security #*Driver's License Number* 5. Person Responsible For AccountName* First Last Relation*Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Driver's License #EmployerWork PhoneSocial Security #*Name of Person Responsible for Appointments* First Last Work Phone 6. Dental / Orthodontic InsuranceOrthodontic Coverage*YesNoInsurance Co. Name:Insurance Co. Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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: Date Format: 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?*YesNoHave there been any injuries to the face, mouth, teeth or chin?*YesNoPlease explain:*List any musical instruments played:Have adenoids or tonsils been removed?*YesNoHas your child been informed of any missing or extra permanent teeth?*YesNoHas your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*YesNoDoes your child brush his/her teeth daily?*YesNoFloss his/her teeth daily?*YesNoChild's Physician*Child's Physician Phone*Is your child currently under the care of a physician?*YesNoHas puberty begun?*YesNoHas menstruation begun? (Girls)YesNoPlease describe your child's current physical health:*GoodFairPoorPlease 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*YesNoAllergies to Any Drugs*YesNoAllergies to Latex/Metals*YesNoAllergies to Plastic*YesNoAny Hospital Stays*YesNoAny Operations*YesNoAsthma*YesNoBruxism/Grinding*YesNoCancer*YesNoClenching*YesNoCongenital Heart Defect*YesNoConvulsions/Epilepsy*YesNoDiabetes*YesNoHandicaps/Disabilities*YesNoHead and Neck Pain*YesNoHeadaches*YesNoHearing Impairment*YesNoHeart Murmur*YesNoHemophilia*YesNoHepatitis*YesNoHIV+/ AIDS*YesNoKeloids*YesNoKidney/Liver Problems*YesNoRheumatic/Scarlet Fever*YesNoSleep Apnea*YesNoSnoring*YesNoTMJ Pain*YesNoTuberculosis(TB)*YesNoADD/ADHD/Aspergers*YesNoPlease discuss any medical problems that your child has had: 9. Does/did your child have any of the following habits?Clenching/Grinding Teeth*YesNoLip Sucking/Biting*YesNoMouth Breather*YesNoNail Biting*YesNoNursing Bottle Habits*YesNoSpeech Problems*YesNoThumb/Finger Sucking*YesNoTongue Thrust*YesNoI 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)*Patient Signature (Sign with Mouse)*Date* Date Format: MM slash DD slash YYYY
973-408-9183
Free Consult
973-408-9183
Free Consult