Child Patient Form

We are really excited to meet you! How did you hear about us? (Select all that apply)
Google
Facebook
Instagram
Referred by a dentist
Referred by a family member
Referred by a friend
Saw your booth at an event
Saw a printed advertisement
Driving by
Other

If you were referred to our practice, whom may we thank for referring you?

Is there anything specific that you would like to change about the appearance of your smile?

What type of treatment are you interested in?
Comprehensive Treatment - "I want everything fixed!"
Limited Treatment. "I just want my teeth straight. I don't care if my bite is off."

Which METHOD of treatment are you most interested in?
Traditional metal braces
Clear ceramic braces
Clear aligner therapy
"I'm open to whatever Dr. Hemphill recommends is best for my case."

What aspects of treatment are most important to you? (Select all that apply)
Quality - "I want the best final result I can possibly get."
Time/Speed - "I want my teeth straightened as fast as possible."
Cost - "I'm looking for the most affordable option."
Experience - "I want to enjoy the process and have a good experience with my treatment."
Questions - "I have a lot of questions about my teeth, and I want to ask a specialist."

We know your time is valuable. Sometimes our schedule allows for starting treatment the same day as your consultation. If time allows, would you be interested in staying after to save yourself a separate trip in the future?
Yes
No
Maybe

Patient's Full Name

Patient's Preferred Name

Patient's Gender

Male
Female

Patient's Date of birth?

Patient's SSN#

Patient's Home Address

City

State

Zip

Phone Number (if applicable)

Email (if applicable)

School

Grade

Hobbies/Interests

Approximate (or exact!) date of last dental cleaning and checkup

Has the child been evaluated by an orthodontist before?

Has the child had orthodontic treatment before?

Have we treated any family members? Please list.

Custodial Parent/Guardian Information

Relationship to the patient?

Full Name

Marital Status

Date of Birth?

SSN#

Cell Phone Number

Cell Phone Carrier

Home Address

City

State

Zip

Email

Employer

Job Title

How long at current job?

Responsible Party Information

Name of person financially responsible for account

Billing Address (if different from Home Address)

City

State

Zip

Phone Number (if different from cell phone)

Email Address

Name of person responsible for scheduling appointments

Phone Number (if different from above)

Email Address (if different from above)

Orthodontic Insurance Information

Do you have orthodontic insurance coverage?

If yes, please fill out the following:

Policy Owner's Name

Policy Owner's Date of Birth

Policy Owner's Relationship to Patient

Insurance Company Name

Insurance Company Address

City

State

Group # (Plan, Local or Policy #)
Zip

Insurance Company Phone Number

Group # (Plan, Local or Policy #)

ID# or SSN

Policy Owner's Employer

Policy Owner's Employer Address

City

State

Zip

Do you have secondary orthodontic insurance?
If yes, please fill out the following:

Secondary Policy Owner's Name

Policy Owner's Date of Birth

Policy Owner's Relationship to Patient

Insurance Company Name

Insurance Company Address

City

State

Zip

Secondary Insurance Company Phone Number

Group # (Plan, Local or Policy #)

ID# or SSN

Policy Owner's Employer

Policy Owner's Employer Address

City

State

Zip

Are you aware of any other disease, condition, or problem not listed above? (If yes, please describe.)

Has the patient ever had any hospital stays or operations? (If yes, please describe.)

Has the patient had tonsils and/or adenoids removed?

Does the patient smoke or use tobacco?

Is the patient under medical care?

Please describe the child's overall physical health:

Has the patient reached puberty?

Is the patient pregnant?

Is the patient currently taking any medications? (If yes, please list them here.)

Is the patient allergic to any drugs/latex/metals/plastics or other things? (If yes, please list allergies and type of reaction.)

Does the child BRUSH his/her teeth daily?

Does the child FLOSS his/her teeth daily?

Have the child had any of the following dental problems?
Fillings
Extractions
Root canals
Crowns
Periodontal (gum) procedures
None of the above

Are you aware of any of the following dental problems?
Trauma/injury to teeth, mouth, jaws, or face
Missing permanent teeth
Extra permanent teeth
Periodontal or "gum" problems
Clicking/popping of the jaw
Jaw discomfort or pain
None of the above

Has a physician or dentist ever recommended that you take antibiotics before a dental appointment?

I certify that the information provided on this form is correct to the best of my knowledge. I understand that it is my responsibility to report any changes.
I agree

Signature: