Child New Patient Information

Child Registration Form - Ortho
* required field

Patient Information






Parent/Guardian Information

Parents' Marital Status
Responsible:







Phone Number:



Phone Number


Emergency Contact



Dental Insurance Information










Dental History


How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?
Has your child's tonsils or adenoids been removed?
Does your child currently or has your child ever had any of the following habits?

Medical History

Does your child have any allergies/sensitivities to medications?
Is your child currently taking any prescription or over-the-counter medications?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.