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 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* 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 InformationParent's Marital Status Single Married Partnered Separated Divorced Widowed Mother/Partner/Guardian Information* Mother Stepmother Partner Guardian Mother/Partner/Guardian Name* First Last Mother/Partner/Guardian Email Address* Enter Email Confirm Email Would you like to receive email updates to this address? Yes No Mother/Partner/Guardian Cell Phone Number*Mother/Partner/Guardian Home Phone NumberMother/Partner/Guardian Employer* Mother/Partner/Guardian Work Phone NumberFather/Partner/Guardian Information* Father Stepfather Partner Guardian Father/Partner/Guardian Name* First Last Father/Partner/Guardian Email Address* Enter Email Confirm Email Would you like to receive email updates to this address? Yes No Father/Partner/Guardian Cell Phone Number*Father/Partner/Guardian Home Phone NumberFather/Partner/Guardian Employer* Father/Partner/Guardian Work Phone NumberInsurance / Billing InformationPerson 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 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 on your dental insurance policy? If no, skip insurance questions. Yes No Insurance Company Name Insurance 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 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 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 for orthodontic treatment before?* Yes No Has your child ever had orthodontic treatment with a different orthodontist?* Yes No If your child has had previous orthodontic treatment please list the type of treatment, approximate dates of treatment, and the Orthodontist's nameHave 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 NumberDate 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.* Untitled Please share...FacebookTwitterGoogle+BufferMore