* required field
Patient Information Parent/Guardian Information Who is financially responsible for this account (main billing party)? * Who will be responsible for bringing the patient to appointments? * Parent/Guardian One Parent Marital Status Parent Marital Status
Relationship Relationship N/A Mother Step-Mother Father Step-Father Guardian Other Name * E-mail* Social Security Number Birth Date * Driver's License Number Address (if different than child's) City State Zip Phone Number Phone Number Phone Type Secondary Phone Number Phone Number Phone Type Employer Occupation
Parent/Guardian Two Relationship N/A Mother Step-Mother Father Step-Father Guardian Other Name E-mail Social Security Number Birth Date Driver's License Address (if different than child's) City State Zip Phone Phone Type Phone Type Secondary Phone Number Secondary Phone Number Phone Type Occupation Employer Emergency Contact Emergency Contact Name (other than parent) Phone Number Relation to child Address City State Zip
Person(s) OK to release appointment or medically related information to concerning child. Relation Dental Insurance Information Please provide your dental insurance details so we can verify your orthodontic benefits before your appointment. If this information is not provided, we may not be able to provide an accurate cost estimate at your visit.
Primary Insurance Company Subscriber (Policyholder) Name Subscriber Birth Date Subscriber SSN Relation to Patient Member ID Number Group Number Employer
Secondary Insurance Company Subscriber (Policyholder) Name Subscriber Birth Date Subscriber SSN Relation to Patient Member ID Number Group Number Employer
Dental History General Dentist * Last Visit *
How did you hear about our Practice? * Name of person referring (if applicable)
What are the main concerns you would like orthodontics to accomplish? *
Has your child visited an orthodontist before? * When? Reason?
Has your child's tonsils or adenoids been removed? * Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? * Does your child you have any missing or extra permanent teeth? * Has your child ever had an injury to (select all that apply): * Does your child have speech problems? * If so, explain: Does your child currently or has your child ever had any of the following habits? * Medical History Is your child currently being treated by a physician? * Reason Physician * Phone * Does your child have any allergies/sensitivities to medications or latex? * If yes, please list allergies: Is your child currently taking any prescription or over-the-counter medications? * Please list, with dosage: Has puberty and/or menstruation begun? * Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate), or Didronel (etidronate)? * Has your child ever taken oral medication for bone disorders or cancers such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate)? * Has your child had any serious illnesses or operations? * If yes, describe: has your child had any serious illnesses or operations? If yes, describe Has your child ever had a blood transfusion? * If yes, give approximate dates: Is your child pregnant? * Nursing? * Taking birth control pills? * Does your child have any diagnosed or suspected emotional, sensory, or developmental conditions? * If yes, please describe: Check if your child has or have ever had any of the following: * 
