We would like fo wekome you ond your rhild to our offire. Our qool ir fo moke everv rhildt visil nleosonf ond edurolionol.We slrive fo feorh good ordl rore fiol will enoble your ihild fo hove o beoutiful smile thof losts o lifetime.

Todoy's Dote:

-

Nicknome:

Age:_ IMole IFemoleI

\rrOOe:

Child's Home #: (-)

CITY

Hm # (_)cell+ 1_1

Who is responsible for merking oppointmenls?Nome:

Do you hove legol custody of this child? I Yes I No

Whom moy we Thonk for referring you?

List broihers ,/ sisters with oge:

Porent's Morirol srorus: 3 i;::h, E i:ilnl E ilffi,

Orthodontic Coveroge? IYes tr No

Insuronce Co. Nome:

Insuronce Co. Phone #: (_)Group # (Plon, Locol, or Policy #):

Fr:i;ry *'*v:r*r's Nome:

Relotionship to Potient:

F*i !cy *.,v*e:-'s Birthdote:

f *l iry i--1''v::er'* Em ployer:

lrisuronce Co. Address:"

Insuronce Co. Phone #' (-)Group # (Plon, Locol, or Policy #):

Pcii*y *.+:n*r's Nome:h I .. | .Keloflonsnrp to rotrenr:

F*f i *y f;r,t':r*r'* Bi rthdote:*:lf ill li! q.:u"i,.icr; 5 EmPlOyef :

[ ffi*gfuerus &e*€*rre*66ecee ! srcp Moiher f Guordion

I Fother's lnformalion:Nome:

IStep Fofier IGuqrdiqn

Hos your child ever token Phen-Fen?(Also known os Redux or Pondimin) lf yes, when?

Hos your child ever been evoluoted or hod orthodontic

treotment before?

Hove there been ony injuries to the

foce, mouth, teeth or chin?

Lisi ony musicol instruments ployed:

Hove odenoids or tonsils been removed? I Yes I No

Hos your child been informed of ony

missing or extro permonent feeth?

Hcs your chilil ever hcd ony pcin / tenderness in hls / her

iow ioint (rMJ / rMDl?

Does your child brush his / her ieeth doily? I Yes I No

Floss his / her teeth doily?

Child's Physicion:

Phone #: (_)_ Dote of Lost Visit:

ls your child currently under thd core of o physicion?

EYes INoEYes INoIYes INo

Pleose describe your chiHt current physicol heolth:DGood I Foir

Pleose list oll drugs thot your child is currently toking:

Pleose list oll drugs / things thot your child is ollergic to:

IYes INo

IYes INo

Hos puberty begun?

Hos menstruotion begun? (Girls)

PleEse discuss ony medicol problems thot your child hos hqd:

N Abnormol Bleeding

N ADD / ADHD

N Allergies to ony Drugs

N Allergic to Lotex / Metols

N Allergic to Plosiic

N Any Hospitol Stoys

N Any OperotionsN Artificiol Bones / Joints /

Volves

N Asthmo

N Concer

N Congeniiol Heort Defeci

N Convulsions / Epilepsy

N Diobetes

N Hondicops / Disobilities

N Heoring lmpoirment

N Heort Murmur

N Hemophilio

N Hepotitis

N HIV+ / AIDS

N Kidney / Liver Problems

N Lupus

N Rheumotic / Scorlet Fever

N Tuberculosis (TB)

'l N Clenching / Grinding Teeth ! N Nursing Bottle Hqbits

t' N Lip Sucking / Biting i N Speech Probtems

v N Mouth Breother 'r' N Thumb / Finger Sucking

r: N Noil Biting J N Tongue Thrusi

Neighbor or Relolive not living with you.

Nome

-Phone

(-)Address

I understond fhot the informotion thot I hove given iscorrect to the best of my knowledge, thot it will be held in the

strictest of confidence ond it is my responsibility to inform thisoffice of ony chonges in my child's medicol stotus.

Ihis office reserves the right to verify the credit stotus of potentiolpotienls ond/or porents of potients prior to extending credit forlreoimenl fees ond moy, ol the discretion of this office, use theservices of one or more credit reporting services.

I outhorize the dentol stoff to perform the necessory dentolservices my child moy need.

Signofure of porent or guordion Dote

lf this office occepts insuronce, I understond thot I qm responsiblefor poyment of services rendered ond olso responsible foi.poyingony co-poyment ond deductibles thot my insuionce does nol cover.I he.reby-outhorize poyment of the group insuronce benefits directlyto this office. I outhorize the use of this signoture on oll myinsuronce submissions, wheiher monuol oi electronic.

Signoture of porenl or guordion Signoture-of porenf or guordion

: I verbolly reviewed ihe medicol / dentol informdtion obove with the porent / guordion ond potient nomed herein.

BRACE YoURsEtF FORM #oRTHo-2c wwrv.informsonline.com o 2ol I lnfOfms 1-8oo.722-4g84 '