Child New Patient Form

Child's/Patient's Information

Name

FirstLast

Date Of Birth

Home Address

Street AddressAddress Line 2CityStateZip Code

Phone

School

Grade

Special interests, sports or hobbies:

Siblings names and ages:

Father’s Information

Name

FirstLast

Date of Birth

Employer

Position

How long?

Address (if different than child's)

Street AddressAddress Line 2CityStateZip Code

Dental Insurance

Home Phone

Cell Phone

Mother’s Information

Name

FirstLast

Date Of Birth

Employer

Position

How Long?

Address (if different than child's)

Street AddressAddress Line 2CityStateZip Code

Dental Insurance

Home Phone

Cell Phone

Person Responsible for Account

Pick One*

Father
Mother
Other

Relationship

Name

FirstLast

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Phone

Cell Phone

Email

* Needed to reply back to you

Do you have orthodontic insurance?

Yes
Now

How did you first hear about our office?

Do you anticipate moving?

Whom may we thank for referring you to our office?

What is your main reason for seeing an orthodontist?

(check all that apply)

Dental Information

Is the Patient concerned about their teeth?

Yes
No

Has Patient had previous treatment for

Gum Disease
TMJ

Who provided previous treatment?

Any previous orthodontics treatment?

No
Yes

When was the last orthodontic treatment?

Is this second opinion?

No
Yes

If yes, why?

Who was the first?

Have other members of the family had orthodontic treatment? If so, whom?

Are they satisfied with the end results?

No
Yes

Is the Patient frightened or anxious about treatment?

No
Yes

Does the patient have any speech problems

No
Yes

Explain

Any injuries to face, head, mouth or teeth?

No
Yes

When?

Pain in or near ears?

No
Yes

When?

Clicking or locking of jaws?

No
Yes

When?

Headaches, facial pain or jaw joint problems?

No
Yes

If so, please explain

General Dentist – Dr.

Date of last visit:

Any other information that would be helpful?

Does patient has any missing or extra teeth?

About Patient Home Care

Please rate patient's oral hygiene:

Fair
Good
Poor

Does patient brush teeth daily?

No
Yes

Does patient floss teeth daily?

No
Yes

Does patient have any history of these habits?

Other related habits

Medical Information

Overall medical health

Poor
Fair
Good

Does patient have any history of following?

Is there tendency to:

Ear Infections
Colds
Sore Throats

Have tonsils and adenoids been removed?

No
Yes

If tonsils/adenoids were removed, when did it happen?

List any drugs or medications being taken

List any allergies or drug sensitivities

Is premeditation needed before dental treatments?

No
Yes

Any other medical problems we should be aware of?

General Physician – Dr.

Date of last visit

Agree To Terms

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 patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of Dr. Masri. I understand that where appropriate, credit bureau reports may be obtained.

*

Yes, I agree to the above terms & conditions.

Child Orthodontic Acquaintance Form

Child's/Patient's Information

Father’s Information

Mother’s Information

Person Responsible for Account

Dental Information

About Patient Home Care

Medical Information

Agree To Terms

Follow Us Online