New Child Patient Form

We would like to welcome you and your child to our office. Our goal is to make every child’s visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

Tell Us About Your Child

Today’s Date:	Nickname:
Child’s Name: Last: First: MI:
E-mail Address:	SS#:
Birthdate: / / Age:	Male / Female
School:	Grade:
Hobbies/ Sports:
Child’s Home #: ( )
Child’s Home Address
City: State: Zip:

Who is Accompanying Your Child Today?

Name: Relation:

Do you have legal custody of this child? Yes / No

Whom may we Thank for referring you?

List brothers/ sisters with age:

General Dentist:

Last Visit Date:

Parent’s Marital Status:
Single / Married / Partnered
Separated / Divorced / Widowed

Mother’s Information

Mother / Step Mother / Guardian

Name: | Birthdate: / /

Wk #: ( ) Ext:
Hm #: ( )

Employer:

How Long at Current Job: | Job Title:

SS # : | DL #:

Father's Information

Father / Step Father / Guardian

Name: | Birthdate: / /

Wk #: ( ) Ext:
Hm #: ( )

Employer:

How Long at Current Job: | Job Title:

SS # : | DL #:

Person Responsible for Account

Name: | Relation:

Billing Address:
City: State: Zip:

Previous Address:
City: State: Zip:

Hm #: ( ) | DL #:

Employer:

Wk #: ( ) Ext: | SS #:

Who is responsible for making appointments?

Name:

Wk #: ( ) Ext: | Hm #:

Primary Orthodontic Insurance

Orthodontic Coverage? Yes / No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #: ( )

Group # (Plan, Local, or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate: / /
ID #:

Policy Owner’s Employer:

Employer’s Address:

Secondary Orthodontic Insurance

Orthodontic Coverage? Yes / No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #: ( )

Group # (Plan, Local, or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate: / /
ID #:

Policy Owner’s Employer:

Employer’s Address:

Background

What are the main concerns that you would like orthodontics to accomplish?
Has your child ever taken Phen-Fen?	Y / N
(Also known as Redux or Pondimin) If yes, when?
Has your child ever been evaluated or had orthodontic treatment before?	Y / N
Have there been any injuries to the face, mouth, teeth or chin?	Y / N
List any musical instruments played:
Have adenoids or tonsils been removed?	Y / N
Has your child been informed of any missing or extra permanent teeth?	Y / N
Has your child ever had any pain/ tenderness in his/her jaw joint (TMJ/ TMD) ?	Y / N
Does your child brush his/her teeth daily?	Y / N
Floss his/her teeth daily?	Y / N
Child’s Physician:
Phone #: ( ) \| Date of Last Visit:
Is your child currently under the care of a physician?	Y / N
Has puberty begun?	Y / N
Has menstruation begun? (Girls)	Y / N
Please describe your child’s current physical health: Good / Fair / Poor
Please list all drugs that your child is currently taking:
Please list all drugs/ things that your child is allergic to:
Y / N Latex \| Y / N Metals/Nickel \| Y / N Plastics

Has your child ever had any of the following medical problems?

Y	N		Y	N
		Abnormal Bleeding			Convulsions/ Epilepsy
		ADD/ADHD			Diabetes
		Allergies to any Drugs			Handicaps/ Disabilities
		Allergic to Latex/ Metals			Hearing Impairment
		Allergic to Plastic			Heart Murmur
		Any Hospital Stays			Hemophilia
		Any Operations			Hepatitis
		Artificial Bones/ Joints/ Valves			HIV+/ AIDS
		Asthma			Kidney/ Liver Problems
		Cancer			Lupus
		Congenital Heart Defect			Rheumatic/ Scarlet Fever
					Tuberculosis (TB)
Please discuss any medical problems that your child has had:

Has your child ever experienced any of the following?

Y	N		Y	N
		Clenching/ Grinding Teeth			Nursing Bottle Habits
		Lip Sucking/ Biting			Speech Problems
		Mouth Breather			Thumb/ Finger Sucking
		Nail Biting			Tongue Thrust

Neighbor or Relative not living with you.

Name: | Phone: ( )

Address:

City: | State: | Zip:

I understand that the information that I have given is correct to the best of my knowledge, that it will be 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 my child may need.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

The Parent or Guardian who accompanies the child is responsible for payment. 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.


You will be asked to verify and sign this form when you visit our office.

tel 562.430.0541
fax 562.598.0005
4608 Katella Ave., Suite 201
Los Alamitos, CA 90720