Tell Us About Your Child
Today’s Date:___________
Person Responsible For Account
Nickname:___________________
CHILD PREFERS TO BE CALLED
Child’s Name:_______________________________________
LASTFIRST
MI
E-mail Address:_____________________ SS#:______________
/ /
Birthdate:______________
Age:_______
Male
Female
Name:______________________ Relation:_________________
Billing Address:________________________________________
_____________________________________________________
CITY
STATE
ZIP
CITY
STATE
ZIP
Previous Address:______________________________________
_____________________________________________________
School:____________________________ Grade:____________
Primary #: (_____) __________________ DL #:______________
Hobbies / Sports:_______________________________________
Secondary #: (_____) __________________ SS #:_____________
Child’s Home #: (_____)________________________________
Employer:__________________ Wk #: (___)__________Ext:_____
Child’s Home Address:______________________________
APT/CONDO #
_____________________________________________________
CITY
STATE
ZIP
Who is Accompanying Your Child Today?
Who is responsible for making appointments?
Name:_______________________________________________
Primary #: (____)______________ Secondary #: (____)____________
Primary Orthodontic Insurance
Name:______________________ Relation:_________________
Orthodontic Coverage?
Do you have legal custody of this child?
Insurance Co. Name:___________________________________
Yes
No
Whom may we Thank for referring you?__________________
List brothers / sisters with age:___________________________
_____________________________________________________
General Dentist:_______________________________________
Last Visit Date:_________________________________________
Parent’s Marital Status:
Single PartneredDivorced
Married SeparatedWidowed
Yes
No
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:____________________________________
Parent:
Mother
Father
Step Parent
Guardian
/ /
Name:__________________________ Birthdate:_______________
Secondary Orthodontic Insurance
Orthodontic Coverage?
Yes
No
Email Address:___________________________________________
Insurance Co. Name:___________________________________
Primary #: (____)______________ Secondary #: (____)____________
Insurance Co. Address:_________________________________
______________________ Wk #: (_____)___________
Insurance Co. Phone #: (_____)__________________________
Employer:
SS #:__________________________ DL #:__________________
Parent:
Father
Mother
Step Parent
Guardian
/ /
Name:__________________________ Birthdate:_______________
Email Address:___________________________________________
Primary #: (____)______________ Secondary #: (____)____________
Group # (Plan, Local, or Policy #):_______________________
Policy Owner’s Name:__________________________________
Relationship to Patient:__________________________________
/ /
Policy Owner’s Birthdate:__________
ID #:________________
______________________ Wk #: (_____)___________
Policy Owner’s Employer:_______________________________
SS #:__________________________ DL #:__________________
Employer’s Address:____________________________________
Employer:
What are the main concerns that you would like
orthodontics to accomplish?______________________
______________________________________________________
Has your child ever been prescribed Fosamax or any
other bisphosphonate? If yes, when?____________
Yes
No
Has your child ever been evaluated or had
orthodontic treatment before?
Yes
No
Have there been any injuries to the face,
mouth, teeth or chin?
Yes
No
List any musical instruments played:_______________________
Has your child ever had any of the
medical problems?
Y N Abnormal Bleeding
Y N ADD / ADHD
Y N Allergies to any Drugs
Y N Allergic to Latex
Y N Allergic to Metals
Y N Allergic to Nickel
Y N Allergic to Plastics
Y N Any Hospital Stays
Y N Any Operations
Y N Artificial Bones / Joints /
Valves
Y N Asperger’s Syndrome
Y NAsthma
Y NAutism
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NCancer
N Congenital Heart Defect
N Convulsions / Epilepsy
NDiabetes
N Handicaps / Disabilities
N Hearing Impairment
N Heart Murmur
NHemophilia
NHepatitis
N HIV+ / AIDS
N Kidney / Liver Problems
NLupus
N Rheumatic / Scarlet Fever
N Tuberculosis (TB)
Have adenoids or tonsils been removed?
Yes
No
Has your child been informed of any missing
or extra permanent teeth?
Yes
No
Has your child ever had any pain / tenderness
in his / her jaw joint (TMJ / TMD)?
Yes
No
Does your child brush his / her teeth daily?
Yes
No
______________________________________________________
Floss his / her teeth daily?
Yes
No
______________________________________________________
Child’s Physician:_______________________________________
______________________________________________________
Phone #: (_____)______________ Date of Last Visit:_________
Is your child currently under the care of a
physician?
Yes
No
Has puberty begun?
Yes
No
Has menstruation begun? (Girls)
Yes
No
Please describe your child’s current physical health:
Good
Fair
Poor
Please list all drugs that your child is currently taking:____________
Please discuss any medical problems that your child has had:
Has your child ever experienced
any of the following?
Y N Clenching / Grinding Teeth
Y N Nursing Bottle Habits
Y N Lip Sucking / Biting
Y N Speech Problems
Y N Mouth Breather
Y N Thumb / Finger Sucking
Y N Nail Biting
Y N Tongue Thrust
__________________________________________________________________
Neighbor or Relative not living with you.
Please list all drugs / things that your child is allergic to:__________
Name____________________________ Phone (____)_______________________
__________________________________________________________________
Address____________________________________________________________
Y N Latex
Y N Metals
Y N Nickel
Y N Plastics
__________________________________________________________________
CITY
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
STATEZIP
I authorize the dental staff to perform the necessary dental
services my child may need.
office of any changes in my child’s medical status.
____________________________________________________________ __________________
Signature of parent or guardian
Date
This office reserves the right to verify the credit status of potential
patients and/or parents of patients prior to extending credit for
treatment fees and may, at the discretion of this office, use the services
of one or more credit reporting services.
If this office accepts insurance, I understand that I am responsible
for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not
cover. I hereby authorize payment of the group insurance benefits
directly to this office. I authorize the use of this signature on all my
insurance submissions, whether manual or electronic.
____________________________________________________________ __________________
Signature of parent or guardian
Date
____________________________________________________________ __________________
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.
I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein.
Doctor’s Comments:
Initials:_________________ Date:____________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
STERN CH-ORTHO-2C V1
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