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 Date Format: MM slash DD slash YYYY Child's Name First Middle Last Name child prefers to be calledChild's Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Birth Date Date Format: MM slash DD slash YYYY Child's AgeChild's GenderMaleFemaleChild's SchoolChild's GradeChild's Hobbies / SportsPerson accompanying child to appointment First Last Relation to the ChildDoes this person have legal custody of this child?YesNoWhom may we thank for referring you?List bothers / sisters with ages:General Dentist NameLast Visit date to Dentist (approximate)Parental InformationParent's Marital StatusSingleMarriedPartneredSeparatedDivorcedWidowedMother / Guardian InformationMotherStepmotherGuardianMother / Guardian Name First Last Mother / Guardian Email Address Enter Email Confirm Email Would you like to receive email updates to this address?YesNoMother / Guardian Cell Phone NumberMother / Guardian Home Phone NumberMother / Guardian EmployerMother / Guardian Work Phone NumberFather / Guardian InformationFatherStepfatherGuardianFather / Guardian Name First Last Father / Guardian Email Address Enter Email Confirm Email Would you like to receive email updates to this address?YesNoFather / Guardian Cell Phone NumberFather / Guardian Home Phone NumberFather / Guardian EmployerFather / Guardian Work Phone NumberInsurance / Billing InformationPerson Responsible for Account First Last Relation to ChildResponsible Billing Party Address (if different from child's address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country INSURANCE - Do you have orthodontic coverage?YesNoInsurance Company NameInsurance Company Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Phone NumberGroup Number (Plan, Local or Policy #)ID#Policy Owner's Name First Last Relationship to PatientPolicy 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 Date Format: MM slash DD slash YYYY Policy Owner's EmployerEmployer's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Objectives and Patient Medical InformationWhat are the main concerns that you would like orthodontics to accomplish?Has your child ever been evaluated or had orthodontic treatment before?YesNoHave adenoids or tonsils been removed?YesNoHas your child been informed of any missing or extra permanent teeth?YesNoHas your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?YesNoDoes your child brush his/her teeth daily?YesNoIs your child currently under the care of a physician?YesNoChild's Physician First Last Physician's Phone NumberDate of Last Visit (approximate)Please describe your child's current physical health:GoodFairPoorPlease list all drugs that your child is currently taking:Please list all drugs / things that your child is allergic to:Allergic to Latex?YesNoAllergic to Metals/Nickel?YesNoAllergic to Plastics?YesNoThird ChoicePlease 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.Untitled Please share...FacebookTwitterGoogle+BufferMore