15230 Levan Road, Across from St Mary Hospital. Livonia, MI 48154
Child New Patient Form - Masri Orthodontics : Get the Smile You Deserve

Child Orthodontic Acquaintance Form

We would like to welcome you and your child to our office. Our goal is to make every child's/patient's visit pleasant and educational. We strive to teach good oral care that will enable our patient's to have a beautiful smile that lasts a lifetime.

Child's/Patient's Information

Father's Information

Mother's Information

Person Responsible for Account

FatherMotherOther

YESNO

Crooked TeethCrowdingClose SpacesCross BiteBad BiteHard to ChewCan't close mouthJaw PainHeadachesDon't like smileCosmetics

Dental Information

YesNo

Gum DiseaseTMJ

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

About Patient Home Care

FairGoodPoor

NoYes

NoYes

Mouth breathingGrinding of teethThumb suckingLeaning on chin or faceNail/lip biting

Medical Information

PoorFairGood

NoYes

NoYes

AsthmaBlood DiseaseDiabetesHepatitisAIDS/HIVBlood DiseaseRheumatic FeverAnemiaHeart DiseaseAllergiesGlaucomaEpilepsyBone DisorderNone
Ear InfectionsColdsSore Throats

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.