Child Patient Information

Name

Date of Birth

Date Today

Home Phone No.

Mobile Phone No.

Email address

School

Grade

Nickname

Whom may we thank for referring you to our office?

Do we see any other family members in the practice?

Responsible Party Information

Add new row

Additional Responsible Party

Add new row

Emergency Information

Name of nearest relative not living with you

Complete address

Home Phone No.

Work Phone No.

Relationship to patient

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. Pitts and Handelin to perform a complete orthodontic evaluation.

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

Date

MEDICAL HISTORY

Physician

Date of Last Visit

Address

Phone No.

Please List

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

DENTAL HISTORY

Dentist

Date of last visit

What concerns you most about your teeth?

Whom may we thank for referring you to our office, other than your dentist?

If yes, who and when?

Female Patients only

If YES, for how long? Fosamax (alendronate), Boniva (ibandronate), Actonel (risedronate) are common names for such drugs

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