Child New Patient Form

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Tell Us About Your Child

Today's Date

MM slash DD slash YYYY

Nickname

Child's First Name(Required)

Child's Middle Name(Required)

Child's Last Name(Required)

Child's Birthdate

MM slash DD slash YYYY

Child's Age

E-mail Address(Required)

School

Grade

Hobbies/Sports

Child's Home Phone Number

Soc. Sec. #

Child's Home Address

Address City State ZIP Code

General Information

Who's accompanying the child today?

Name

Relation

Do you have legal custody of this child?

Whom may we thank for referring you?

Other siblings/ages

General Dentist

Dentist Phone

Last Visit Date

MM slash DD slash YYYY

Relative or friend not living with you:

Name

First Last

Phone

Address

Address City State ZIP Code

Parent's Information

Who is responsible for account

First Last

Marital Status

Single

Married

Partnered

Widowed

Divorced

Separated

Relation to

Father

Stepfather

Guardian

Name

First Last

Birthdate

MM slash DD slash YYYY

Address (if different than child's)

Address City State ZIP Code

Home Phone Number

SS #

DL #

Work

Cell

Employer

Occupation

Employer Address

Address City State ZIP Code

If you have orthodontic insurance coverage for the child, please fill out below:

Insurance Company

Insurance Address

Address City State ZIP Code

Insurance Phone Number

Insured's ID

Group Number (Plan, Local or Policy #)

Relation to

Mother

Stepmother

Guardian

Name

First Last

Birthdate

MM slash DD slash YYYY

Address (if different than child's)

Address City State ZIP Code

Home Phone Number

SS #

DL #

Work

Cell

Employer

Occupation

Employer Address

Address City State ZIP Code

If you have orthodontic insurance coverage for the child, please fill out below:

Insurance Company

Insurance Address

Address City State ZIP Code

Insurance Phone Number

Insured's ID

Group Number (Plan, Local or Policy #)

What would you like us to do today?

Are you in dental discomfort today?

Former Dentist

Address

Phone

Dentist's Email

Date of last dental care

Date of last X-rays

Bad Breath

Food collection between teeth

Periodontal treatment

Sensitivity to sweets

Bleeding gums

Grinding or clenching teeth

Sensitivity to cold

Sensitivity when biting

Clicking or popping jaw

Loose teeth or broken fillings

Sensitivity to hot

Sores or growths in mouth

How often do you brush?

How often do you floss?

How do you feel about the appearance of your teeth?

Do you wish your teeth were straighter?

Do you wish your teeth were whiter?

Are you unhappy with the fillings, crowns, or bridges?

Have you experienced an adverse reaction during or in conjunction with a medical or dental procedure?

Dental and Medical History

What are the main concerns that you would like orthodontics to accomplish?

Has your child ever been evaluated or had orthodontic treatment before?

Have there been any injuries to the face, mouth, teeth or chin?

Does the child require antibiotics before dental treatment?

Have adenoids or tonsils been removed?

Does your child have any missing or extra permanent teeth?

Has the child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?

Does the child brush teeth daily?

Floss daily?

Child's Physician:

Ph #:

Date of last visit:

MM slash DD slash YYYY

Is the child currently under the care of a physician?

Has puberty begun?

GIRLS: Has menstruation begun?

Indicate the child's current physical health:

Good

Fair

Poor

Please list all drugs that the child is currently taking:

Does your child have allergies to any of the following?

Latex

Nickel/Metals

Plastic

Please list any other allergies that the child may have:

Has the child experienced any of the following medical problems?

Abnormal Bleeding

Hearing Impairment

ADD/ADHD

Heart Murmur

AIDS/HIV+

Hemophilia

Any Hospital Stays/Operations

Hepatitis

Artificial Bones/Joints/Valves

Kidney Problems

Asthma

Liver Problems

Cancer

Mitral Valve Prolapse

Congenital Heart Defect

Prosthetics

Convulsions

Rheumatic Fever

Diabetes

Scarlet Fever

Epilepsy

Sickle Cell Disease/Traits

Handicaps/Disabilities

Tuberculosis (TB)

Has the child ever taken any diet pills such as Phen-Fen?

(Also known as Redux or Pondimin) If so, when?

Are the child's immunizations current?

Would you like to discuss anything with the Doctor in private?

Please list any serious medical problems the child has had:

Breast Fed

Nursing/Bottle Habits

Clenching/Grinding Teeth

Speech Problems

Lip Sucking/Biting

Thumb/Finger Sucking

Mouth Breather

Tongue Thrust

Nail Biting

Pacifier Usage

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that 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/orth- odontic services that my child may need.

SIGNATURE OF PARENT OR GUARDIAN(Required)

Date(Required)

MM slash DD slash YYYY

OFFICE USE ONLY

Doctor's Comments:

SIGNATURE OF DOCTOR

Medical History Update

Has there been any change in your child's health status since their last visit?

If yes, please explain:

PARENT/GUARDIAN SIGNATURE

Signature

3151 South White Road, Suite #103 San Jose, California