Child New Patient Form

Date

Patient's Last Name

First Name

Middle

Nick Name

Birthdate

School

Sports / Hobbies

Whom may we thank for referring you to our office?

RESPONSIBLE PARTY INFORMATION

Last Name

First Name

Middle

Mailing Address

City

State

Zip Code

Home Phone

Cell Phone

Email address

Birthdate

Relationship to Patient

Employer

Occupation

Spouse’s Name

Relationship to Patient

Work Phone

Employer

Occupation

Birthdate

DENTAL INSURANCE INFORMATION

Insured’s Name

Insured’s Social Security No.

Insurance Company

Group No.

Member ID No.

Insurance Co. Address

Phone No.

Do you have dual coverage?

Yes No

If yes,

Insured’s Name

Insured’s Social Security No.

Insurance Company

Group No.

Member ID No.

Insurance Co. Address

Phone No.

EMERGENCY INFORMATION

Name of nearest relative not living with you

Mailing address

City

State

Phone

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent Signature

MEDICAL HISTORY

Physician

Date of Last Visit

Phone

Please circle Yes or No (If Yes, please fill in details)

Is the patient taking any medication?

Yes No

If yes, please explain

Is the patient allergic to any medication?

Yes No

If yes, please explain

History of a major illness?

Yes No

If yes, please explain

Has the patient had any operations?

Yes No

If yes, please explain

Have seen a physician in the last 12 months?

Yes No

If yes, Why?

Have your tonsils or adenoids been removed?

Yes No

When

Female Patients only:

Has menstruation started?

Yes No

Is the patient pregnant?

Yes No

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY

General Dentist

Date of Last visit

What concerns you most about your teeth?

Is the patient presently in any dental pain?

Yes No

If yes, please explain

Has the patient ever lost or chipped any teeth?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Is any part of your mouth sensitive to temperature or pressure?

Yes No

Where?

Do gums bleed when brushing?

Yes No

If yes, please explain

Any type of thumb or tongue habit?

Yes No

If yes, please explain

Is the patient a mouth breather?

Yes No

If yes, please explain

Has the patient ever seen an orthodontist?

Yes No

If yes, who and when?

Do teeth or jaws ever feel uncomfortable first thing in the morning?

Yes No

If yes, please explain

Experience jaw clicking or popping?

Yes No

If yes, please explain

Aware of clenching or grinding teeth during the day?

Yes No

If yes, please explain

Experience “tension” headaches?

Yes No

If yes, please explain

Has the patient ever experienced chronic ringing in the ears?

Yes No

If yes, please explain

Does the patient need extra help with instructions?

Yes No

If yes, please explain

Is the patient sensitive or self-conscious about his/her teeth?

Yes No

If yes, please explain

Are you aware that some appointments will be during school hours?

Yes No

BENEFITS

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Robert Bourquein perform a complete orthodontic evaluation

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.