To the Orthodontist

We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

1 Tell Us About Your Child

Today's Date:


Child's Name:

Email Address: SS#



Sex: MaleFemale



Hobbies / Sports:

Child's Home

Child's Home Address:

2 Who is accompanying your child today?



Do you have legal custody of this child? YesNo

Whom may we Thank for referring you?

List brothers / sisters with age:

General Dentist:

Last Visit Date:

Parent's Marital Status: SinglePartneredDivorcedMarried


Parent: MotherFatherStep ParentGuardian



Email Address:

Cell #:

Hm #


Wk #:

SS #:

DL #:

Child's Home:

4 Person Responsible For Account



Billing Address:

Previous Address:

Hm #:

DL #

Cell #:

SS #


Wk #:


5 Primary Orthodontic Insurance

Orthodontic Coverage? YesNo

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Policy Owner's Name:

Relationship to Patient:

SS #

Policy Owner's Birthday:

ID #:

Policy Owner's Employer:

Employer's Address:

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

Has your child ever been prescribed Fosamax YesNo

or any other bisphosphonate? if yes, when?

Has your child ever been evaluated or had othodontic treatment before? YesNo

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

List any musical instruments played

Have adenoids or tonsils been removed? YesNo

Has your child been informed of any missing or extra permanent teeth? YesNo

Has your child ever had any pain / tenderness in his / her jaw joint (TMj/ TMD)? YesNo

Does your child brush his / her teeth daily? YesNo

Floss his / her teeth daily? YesNo

Child's Dentist:

Phone #:

Date of Last Visit:

Is your child currently under the care of a physician? YesNo

Has puberty begun? YesNo

Has menstruation begun? (Girls) YesNo

Has describe your child's current physical health? GoodFairPoor

Please list all drugs that your child is currently taking:

Please list all drugs / things that your child is allergic to:

Latex YesNo

Metals / Nickel YesNo

Plastics YesNo

7 Has your child ever had any of the following medical problems?

YesNo Abnormal Bleeding


YesNo Allergies to any Drugs

YesNo Allergies to Latex / Metals

YesNo Allergies to Plastic

YesNo Any Hospital Stays

YesNo Any Operations

YesNo Artificial Bones / Joints / Valves

YesNo Asperger Syndrome

YesNo Asthma

YesNo Cancer

YesNo Congenital Heart Defect

YesNo Convulsions / Epilepsy

YesNo Diabetes

YesNo Handicaps / Disabilities

YesNo Hearing Impairment

YesNo Heart Murmur

YesNo Hemophilia

YesNo Hepatitis


YesNo Kidney / Liver Problems

YesNo Lupus

YesNo Rheumatic / Scarlet Fever

YesNo Tuberculosis

Please discuss any medical problems that your child has had:

8 Has your child ever experienced any of the following?

YesNo Clenching / Grinding Teeth

YesNo Lip Sucking / Biting

YesNo Lip Mouth Breather

YesNo Nail Biting

YesNo Nursing Bottle Habits

YesNo Speech Problems

YesNo Thumb / Finger Sucking

YesNo Tongue Thrust

Neighbor or Relative not living with you.







9I 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.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment frees and may, at the discretion of this office, use the services of one or more credit reporting services.

I authorize the dental staff to perform the necessary dental services my child may need.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

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