Child New Patient Form

Patient's Name

Date of Birth

Age

Patient Prefers to be called

Telephone No.

Home Address

Zip Code

School

Grade

Family Dentist

Patient's Hobbies or Interests

Whom may we thank for referring you?

Father's Name

Occupation

Employed By

Business Telephone No.

Business Address

Soc Sec No.

Name of Person Responsible for Account

Relationship to Patient

Name of Ages or Other Children in Family

Name of Insurance Company

Is orthodontic coverage with mother, father, both, or other?

Illness

List any medicines your child is currently taking

List any drug sensitivities

Is there a history of serious illness, accident or operation?

If so, list

If yes Month / Year?

Please complete the following information as accurately as possible to help us evaluate family growth pattern.

Father: Weight

Mother: Height

Patient: Height

Weight

DENTAL HISTORY

Until What age?

If so, by whom?

Please list any family members previously treated here

What part of your child's orthodontic problem concerns you most?

Additional information which you feel would help make your child's association with us more enjoyable

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.

Signature of Parent or Guardian

Date

Your information will be encrypted.