New Patient Form (Child)

Thank you for your interest in our office! Please complete both sides of this form while you wait to be seated.

Patient Name

Date of Birth

Age

Nickname

Siblings Names/Ages

Hobbies/Interests

Dentist

How did you hear about us?

Primary Responsible Party: Please list the person(s) responsible for this account. For divorced/separated parents, please list both parties' information - our office requires consent from both parties to treat patients.

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If you need split responsible party payments, Please check this box

Secondary Responsible Party: (If applicable)

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Please list all (if any) allergies

Please list all (if any) medications taken

If so, please explain

Any major falls, accidents, or operations?

Any other medical information we should know about?

What in particular brings you in for an orthodontic evaluation? (Any main concerns?)

Would you like to have braces if recommended?

DISCLAIMER: 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.

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New Patient Form (Child)

HOLLAND ORTHODONTICS