Child New Patient Intake Form

Please complete this form at least 24 hours prior to your appointment with us so that we may better serve you.

Today's Date
MM slash DD slash YYYY
Child's Name
First Middle Last
Name child prefers to be called
Child's Home Address
Street Address Address Line 2 City State ZIP Code
Child's Birth Date
MM slash DD slash YYYY
Child's Age
Child's Gender
- Male
- Female
Child's School
Child's Grade
Child's Hobbies / Sports
Person accompanying child to appointment
First Last
Relation to the Child
Does this person have legal custody of this child?
- Yes
- No
Whom may we thank for referring you?
List bothers / sisters with ages:
General Dentist Name
Last Visit date to Dentist (approximate)
Parental Information
Parent's Marital Status
- Single
- Married
- Partnered
- Separated
- Divorced
- Widowed
Mother / Guardian Information
- Mother
- Stepmother
- Guardian
Mother / Guardian Name
First Last
Mother / Guardian Email Address
Enter Email Confirm Email
Would you like to receive email updates to this address?
- Yes
- No
Mother / Guardian Cell Phone Number
Mother / Guardian Home Phone Number
Mother / Guardian Employer
Mother / Guardian Work Phone Number
Father / Guardian Information
- Father
- Stepfather
- Guardian
Father / Guardian Name
First Last
Father / Guardian Email Address
Enter Email Confirm Email
Would you like to receive email updates to this address?
- Yes
- No
Father / Guardian Cell Phone Number
Father / Guardian Home Phone Number
Father / Guardian Employer
Father / Guardian Work Phone Number
Insurance / Billing Information
Person Responsible for Account
First Last
Relation to Child
Responsible Billing Party Address (if different from child's address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
INSURANCE - Do you have orthodontic coverage?
- Yes
- No
Insurance Company Name
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Phone Number
Group Number (Plan, Local or Policy #)
ID#
Policy Owner's Name
First Last
Relationship to Patient
Policy Owner's Social Security Number (required to file some insurances)
This is a secure site and all information will be kept strictly confidential.
Policy Owner's Birthdate
MM slash DD slash YYYY
Policy Owner's Employer
Employer's Address
Street Address Address Line 2 City State ZIP Code
Objectives and Patient Medical Information
What are the main concerns that you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?
- Yes
- No
Have adenoids or tonsils been removed?
- Yes
- No
Has your child been informed of any missing or extra permanent teeth?
- Yes
- No
Has your child ever had trauma to their teeth or been in an accident involving their teeth/mouth?
- Yes
- No
If you answered yes, please give a brief description:
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
- Yes
- No
Does your child brush his/her teeth daily?
- Yes
- No
Is your child currently under the care of a physician?
- Yes
- No
Child's Physician
First Last
Physician's Phone Number
Date of Last Visit (approximate)
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:
Allergic to Latex?
- Yes
- No
Allergic to Metals/Nickel?
- Yes
- No
Allergic to Plastics?
- Yes
- No
- Third Choice
Please check any of the following medical problems that your child has ever had:
- Abnormal Bleeding
- ADD / ADHD
- Allergies to any Drugs
- Allergies to Latex / Metals
- Allergic to Plastic
- Any Hospital Stays
- Any Operations
- Artificial Bones / Joints / Valves
- Asthma
- Cancer
- Congenital Heart Defect
- Convulsions / Epilepsy
- Diabetes
- Handicaps / Disabilities
- Hearing Impairment
- Heart Murmur
- Hemophilia
- Hepatitis
- HIV+ / AIDS
- Kidney / Liver Problems
- Lupus
- Rheumatic / Scarlet Fever
- Tuberculosis (TB)
- None
Please discuss any medical problems that your child has had:
Please check any of the following that your child has ever experienced:
- Clenching / Grinding Teeth
- Lip Sucking / Biting
- Mouth Breather
- Nail Biting
- Nursing Bottle Habits
- Speech Problems
- Thumb / Finger Sucking
- Tongue Thrust
- None
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.

Parental Information

Insurance / Billing Information

Objectives and Patient Medical Information

Bentley Orthodontics