TO THE ORTHODONTIST: We would like to welcome you and your child to our office.Our goal is to make every child’s visit pleasant and educational. We strive to teach good oral care

that will enable your child to have a beautiful smile that lasts a lifetime.

Tell Us About Your Child

Today’s Date: ____________ Nickname:__________________NAME CHILD LIKES TO BE CALLED

Child’s Name: _____________________________________LAST FIRST MI

E-mail Address: ____________________ SS#: ______________

Birthdate: _______________Age:_________ Male Female

School: ___________________________Grade: _____________

Hobbies / Sports: _____________________________________

Child’s Hm #: (_____) ________ Cell #: (_____) _____________

Child’s Home Address: ___________________________APT/CONDO #

_____________________________________________________CITY STATE ZIP

Person Responsible For Account

Who Is Accompanying Your Child Today?Name:______________________ Relation: ________________

Do you have legal custody of this child? Yes NoWho may we thank for referring you?____________________

List brothers / sisters with age: __________________________

_____________________________________________________

General Dentist: _______________________________________

Last Visit Date: ________________________________________

Parent’s Marital Status:

Mother’s Information: Step Mother Guardian

Email: ________________________________ Cell #:___________________

Name: __________________________ Birthdate: ______________Wk #: (_____) ____________Ext: ____ Hm #: (_____) __________Employer:______________________________________________How long at current job:______ Job Title: ____________________SS #: __________________________ DL #: _________________

Father’s Information: Step Father Guardian

Email: ________________________________ Cell #:___________________

Name: __________________________ Birthdate: _____________Wk #: (_____) ____________Ext: ____ Hm #:(_____) ___________Employer:______________________________________________How long at current job:______ Job Title: ____________________SS #: __________________________DL #: ___________________

Orthodontic Insurance

CONTINUED ON BACK

Primary Orthodontic InsuranceOrthodontic Coverage? Yes No

Insurance Co. Name:___________________________________

Insurance Co. Address: _________________________________

Insurance Co. Phone #: (_____) __________________________

Group # (Plan, Local, or Policy #):________________________

Policy Owner’s Name:__________________________________

Relationship to Patient: _________________________________

Policy Owner’s Birthdate: _________ID #: _________________

Policy Owner’s Employer: _______________________________

Employer’s Address: ___________________________________

Secondary Orthodontic InsuranceOrthodontic Coverage? Yes No

Insurance Co. Name:___________________________________

Insurance Co. Address: _________________________________

Insurance Co. Phone #: (_____) __________________________

Group # (Plan, Local, or Policy #):________________________

Policy Owner’s Name:__________________________________

Relationship to Patient: _________________________________

Policy Owner’s Birthdate: _________ID #: _________________

Policy Owner’s Employer: _______________________________

Employer’s Address: ___________________________________

/ /

/ /

/ // /

/ /

Single Partnered DivorcedMarried Separated Widowed

Name:______________________ Relation: ________________Billing Address: ____________________________________________________________________________________________

CITY STATE ZIP

Previous Address: __________________________________________________________________________________________

CITY STATE ZIP

Hm #: (_____) _________________DL #: __________________Employer: ____________________________________________Wk #: (_____) _________ Ext: _____ SS #: ________________

Who is responsible for making appointments?Name: _______________________________________________Wk #: (_____) _________ Ext: _____ Hm #:________________GHT

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Visit Date: ____________

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Has your child ever had any of thefollowing medical problems?

Y N Abnormal BleedingY N ADD / ADHDY N Allergies to any DrugsY N Allergic to Latex / MetalsY N Allergic to PlasticY N Any Hospital StaysY N Any OperationsY N Artificial Bones / Joints /

ValvesY N AsthmaY N CancerY N Congenital Heart Defect

Y N Convulsions / EpilepsyY N DiabetesY N Handicaps / DisabilitiesY N Hearing ImpairmentY N Heart MurmurY N HemophiliaY N HepatitisY N HIV+ / AIDSY N Kidney / Liver ProblemsY N LupusY N Rheumatic / Scarlet FeverY N Tuberculosis (TB)

Has your child ever experienced any of the following?

Y N Clenching / Grinding Teeth

Y N Lip Sucking / Biting

Y N Mouth Breather

Y N Nail Biting

Y N Nursing Bottle Habits

Y N Speech Problems

Y N Thumb / Finger Sucking

Y N Tongue Thrust

Please discuss any medical problems that your child has had:

______________________________________________________

______________________________________________________

______________________________________________________

What are the main concerns that you would likeorthodontics to accomplish?_______________________

______________________________________________________

Has your child ever been prescribed Fosamaxor any other Bisphosphonate? Yes No

Has your child ever been evaluated or had orthodontictreatment before? Yes No

Have there been any injuries to theface, mouth, teeth or chin? Yes No

List any musical instruments played: _______________________Have adenoids or tonsils been removed? Yes NoHas your child been informed of any

missing or extra permanent teeth? Yes NoHas your child ever had any pain / tenderness in his / her

jaw joint (TMJ / TMD)? Yes NoDoes your child brush his / her teeth daily? Yes NoFloss his / her teeth daily? Yes NoChild’s Physician: _______________________________________Phone #: (_____) ______________Date of Last Visit: __________Is your child currently under the care of a physician?

Yes NoHas puberty begun? Yes NoHas menstruation begun? (Girls) Yes NoPlease describe your child’s current physical health:

Good Fair Poor

Please list all drugs that your child is currently taking: ________________________________________________________________

Please list all drugs / things that your child is allergic to: ______________________________________________________________Y N Latex Y N Metals/Nickel Y N Plastics

I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein.

Doctor’s Comments: Initials:________________ Date: ____________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

FORM #550-ORTHO-C SMILING BRACES www.informsonline.com © 2014 1-800-722-4884

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 thisoffice of any changes in my child’s medical status.

I authorize the dental staff to perform the necessary dentalservices my child may need.

__________________________________________________________Signature of parent or guardian Date

The Parent or Guardian who accompanies the child is responsible for payment.Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

This office reserves the right to verify the credit status of potentialpatients and/or parents of patients prior to extending credit fortreatment fees and may, at the discretion of this office, use theservices of one or more credit reporting services.

__________________________________________________________Signature of parent or guardian Date

If this office accepts insurance, I understand that I am responsible forpayment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I herebyauthorize payment of the group insurance benefits directly to this office.

____________________________________________________________Signature of parent or guardian Date

Neighbor or Relative not living with you.

Name______________________ Phone (____) _______________Address _____________________________________________________________________________________________________CITY STATE ZIP

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