Child Patient Form

Please fill out this form completely, it is important for your dental care. Our goal is to help you reach and maintain good oral health.

TELL US ABOUT YOUR CHILD

Child’s Name: (Last, First, MI)

Date of Birth

Age

Today’s Date

Nickname

What is your child's gender?

Male

Female

Other

What gender does your child identify as?

What are the patients preferred pronouns?

School

Grade

Hobbies / Sports

Child’s Home Address

City

State

Zip Code

Child’s Home Phone No.

WHO IS ACCOMPANYING YOUR CHILD TODAY?

Name

Relation

Whom may we thank for referring you?

List other family members seen by us

General Dentist

Date of last cleaning / visit

Parent’s Marital Status

Single Married Partnered Separated Divorced Widowed

PARENTAL INFORMATION

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PERSON RESPONSIBLE FOR THE ACCOUNT

Name

Relation

Billing Address

City

State

Zip Code

City

State

Zip Code

Home Phone No.

Cell Phone No.

Work Phone No.

Employer

Who is responsible for making appointments?

Name

Cell Phone No.

Home Phone No.

Work Phone No.

Birthdate

Relationship

Cell Phone No.

DENTAL INSURANCE • PRIMARY

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DENTAL INSURANCE • SECONDARY

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WHAT WOULD YOU LIKE ORTHODONTICS TO ACCOMPLISH?

List any musical instruments played

Child’s Physician

Phone No.

Date of Last Visit

Please list all medications your child is currently taking

Please list all medications/things your child is allergic to

Please discuss any medical problems your child has had

EMERGENCY CONTACT: RELATIVE OR FRIEND

Name

Home Phone No.

Cell Phone No.

Address

City

State

Zip

I understand that the information that I have given today is correct to the best of my knowledge, that it is held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services that my child may need.

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

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Your information will be encrypted.