New Child Patient Form (Page 2 of 3) in pdf

NSURANCE

NFORMATION

Primary Insurance Company ________________________

Phone Number ______________

Group # _________________

Policy # ________________ Member ID # ________________

Policy Holder’s Name _______________________________ Relation ___________________

Policy Holder’s Social Security # _______________ Policy Holder’s Birth Date ____________

Employer ______________________________________

Work Phone # ________________

Co-pay (if known) _______________ Deductible (if known) ___________________________

Secondary Insurance Company ____________________

Phone Number ________________

Group # _________________

Policy # ________________ Member ID # ________________

Policy Holder’s Name ________________________________ Relation __________________

Policy Holder’s Social Security # _______________ Policy Holder’s Birth Date ____________

Employer _______________________________________

Work Phone # _______________

Co-pay (if known) _______________ Deductible (if known) ___________________________

ENTAL

ISTORY

General Dentist ________________________________

Last Visit _____________________

How did you hear about our Practice?

 Ad  Internet

 Family or Friend

 Physician

 Other

Name of person referring (if applicable) ____________________________________________

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

____________________________________________________________________________

Has your child visited an orthodontist before?  Y  N

When? ____________________

Reason? ________________________________________

Have we treated any other family members?  Y  N

Name ________________________

Have your child’s tonsils or adenoids been removed?  Y  N

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD) ?  Y  N

Does your child have any missing or extra permanent teeth?  Y  N

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

 Mouth

 Chin

Does your child have speech problems?  Y  N

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

Mouth Breathing

Thumb / Finger Sucking



Lip Sucking/Biting

Nail biting

Chewing / Eating Problem

EDICAL

ISTORY

Is your child currently being treated by a physician?  Y  N Reason __________________

Physician ________________________

Last Visit ______________ Phone ____________

Does your child have any allergies/sensitivities to medications or latex?  Y  N

If yes, please list.

____________________________________________________________________________

Is your child currently taking any prescription or over-the-counter medications?  Y  N

Please list, with dosage. _______________________________________________________

Has puberty and/or menstruation begun?  Y  N  N/A

New Child Patient Form Page 2

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