Child New Patient Information

Child Registration Form - Ortho
* required field

Patient Information







Primary Phone Number




Parent/Guardian Information

Parents' Marital Status







Phone Number
Secondary Phone Number








Phone
Secondary Phone Number

Emergency Contact








Dental Insurance Information

























Dental History


How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?

Has your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child you have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?



Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?





Check if your child has or have ever had any of the following:

Authorization and HIPAA Notice of Privacy Practices

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for healthcare operations like quality reviews.

I've been informed that I may review the practice Notice of Privacy Practices (For a more complete description of uses and disclosures) before signing this consent.

I understand that the practice has the right to change their privacy practices and I may obtain any revised notice of the practice.

I understand that I have the right to request a restriction of how my protected health information is used. However I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow the restriction(s).

I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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