Child Information Form

Patient Information
Child Patient's Name*
Middle Name
Nickname
Gender*
SSN

(enter without dashes) (Note: this field will be encrypted for your personal safety)
Date of Birth*
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
School District*
Grade
Dentist
Dentist Phone
Family Physician
Family Physician Phone
Which office will you be visiting?

Father / Guardian's Information
Father / Guardian's Full Name
Middle Name
Relation to Child / Patient
Date of Birth
MM slash DD slash YYYY
SSN

(Enter without dashes) (Note: this field will be encrypted for your personal safety)
Does the Child and Guardian have the same address?*
- Yes
- No
Home Address (Skip if same)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Father / Guardian Cell Phone
Email Address
Employer
Occupation
Business Phone
Person/Person's responsible for payment of account:

(*In cases where parents are divorced/seperated, we hold the parent/guardian who accompanies the child responsible)
Orthodontic Insurance Carrier & ID (if any)
Emergency Contact Name:*
Emergency Contact Phone Number*
Emergency Contact Relationship:*

Mother / 2nd Guardian's Information
Mother / 2nd Guardian's Full Name
Middle Name
Date of Birth
MM slash DD slash YYYY
SSN

(Enter without dashes) (Note: this field will be encrypted for your personal safety)
Does the Child and Guardian have the same address?
- Yes
- No
Home Address (Skip if same)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mother /2nd Guardian Cell Phone
Email Address

example@example.com
Employer
Occupation
Business Phone
Orthodontic Insurance Carrier & ID (if any)

Dental History
Have you had any severe head or facial injuries?
If YES, When?
Do you have past history of thumb or finger sucking?
Have you previously consulted any Orthodontist?
If YES, Where?
Have you had any previous orthodontic treatment?
If YES, please list previous Doctor:
Have any other family members had orthodontic treatment in our office?
- Yes
- No
If yes, Please list Full Names:
Is there any other information which may be helpful?
Why are you seeking orthodontic care?
Whom may we thank for referring you to our practice?
Signature*
Please note:There is no fee for the initial consultation. There is a fee for diagnostic records if the doctor elects to treat them at the initial appointment, or at any other time.Payment is expected at the time of these services. You will be notified of any charges before they occur.

Patient Information