Bring-along form for Child

Registration form for Children

Please fill this form online, print it, and bring the printout with you before your appointment.

Today's Date:

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Child's Name:

Sex:

Child's Birthdate:

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Age:

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School:

Grade:

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Hobbies & Interests:

Phone Number:

Home Address Street:

City:

ZIP:

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Email:

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Name of person accompanying the child:

Do you have legal custody of this child?

Whom may we thank for referring you?

Siblings' Names / Ages:

General Dentist:

Date of Last Cleaning/Visit:

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Relationship:

Name of Father/Stepfather/Guardian:

Parents' Marital Status:

Phone Number:

Relationship:

Name of Mother/Stepmother/Guardian:

Phone Number:

Relationship:

Name of Person responsible for Account:

Billing Address Street:

City:

ZIP:

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Phone Number:

Email:

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Employer:

Work phone Number:

SSN (to be filled at office):

Primary Orthodontic Coverage? Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone Number:

Group # ( Plan, Local or Policy # ):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate:

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Policy Owner's ID:

Policy Owner's Employer:

Employer's Address:

Secondary Orthodontic Insurance Coverage ? Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone Number:

Group # ( Plan, Local or Policy # ):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate:

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Policy Owner's ID:

Policy Owner's Employer:

Employer's Address:

What would you like Orthodontics to accomplish:

Has your child ever taken Phen-Fen: Yes No

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

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

Does your child floss his/her teeth daily? Yes No

Child's Physician:

Physician's Phone Number:

Date of last visit:

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Is your child in care of a physician: Yes No

Has puberty begun? Yes No

Has menstrual cycle begun (Girls) ? Yes No

List all drugs your child is currently taking (or write None)

List all drugs your child is allergic to:

Latex Allergy: Yes No

Metals/Nickel Allergy: Yes No

Plastics Allergy: yes No

Has your child ever had Abnormal Bleeding: Yes No

ADD/ADHD: Yes No

Hospital Stays: yes No

Any operations: Yes No

Artificial Bones/Joints: Yes No

Artificial Valves: Yes No

Cancer: Yes No

Congenital Heart Defect: Yes No

Convulstions / Epilepsy: Yes No

Handicaps / Disabilities: Yes No

Diabetes: Yes no

Hearing Impairment: Yes No

Heart Murmur: Yes No

Hepatitis: Yes No

HIV+ / AIDS: Yes No

Kidney / Liver Problems: Yes No

Lupus: Yes No

Rheumatic / Scarlet Fever: Yes No

Tuberculosis (TB): Yes No

Please discuss any medical problems your child has had:

Has your child ever experienced 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

Name of Neighbor or Friend not living with you:

Phone Number:

Acknowledgement: I understand that the information I've given is correct to the best of my knowledge, that it will be held in strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. (Sign & Date in the box)

Sign & Date Acknowledgement:

Credit verification declaration: 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 this office, use one/more credit reporting services (Sign)

Sign & Date Credit Acknowledgement:

Sign & Date Insurance Acknowledgement:

Acknowledgement of Insurance Liability: If this office accepts insurance, I understand that I am responsible for payment of services rendered and also any co-payment and deductibles. I hereby authorize payment of group insurance benefits directly to this office (sign/date).

Office use Only: I have verbally reviewed the medical/dental information above with the parent/guardian and patient named herein (Doctor's comments please write here).

Doctor's Initials:

Date:

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For Office use only: SSN: DL:

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