Child Registration Form

Patient Information

Patient Name

Gender

Patient Social Security Number

Patient Birth Date

Patient Age

Patient Home Address

City
State

Zip

Primary Phone Number
Email

School

Grade

List any sports or extracurricular activities

Siblings - names and ages

Parent / Guardian Information

Mother:

Name

Marital Status

Relation to Child

Social Security Number

Birth Date

Drivers License Number

Address - if different than child

City

State

Zip

Primary Phone

Secondary Phone

Employer Name

Occupation

Father:

Name

Marital Status

Relation to Child

Social Security Number

Birth Date

Drivers License Number

Address - if different than child

City

State

Zip

Primary Phone

Secondary Phone

Employer Name

Occupation

Emergency Contact Information

Emergency Contact Name -other than parent

Phone Number

Relation to ChildAddress

State

Zip

Person or persons you allow us to release appointment or medically-related information regarding your child to

Relation or Relations to Child

Insurance Information

Primary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Co-pay - if know

Deductible - if known

Policy Holder Name

Relation to Patient

Policy Holder SSN

Birth Date

Employer

Work Phone Number

Secondary Insurance

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Co-pay - if known

Deductible - if known

Policy Holder Name

Relation to Patient

Policy Holder SSN

Birth Date

Employer

Work Phone Number

Dental History

General Dentist

How did you hear about our practice?

Name of person referring - if applicable

What are the main concerns you would like orthodontics to correct?

Has your child visited an orthodontist before?

If yes, when?

Reason

List Any Family Members We Have Treated

Have your childs tonsils or adenoids been removed?

Has your child ever experienced jaw joint pain/discomfort - TMJ/TMD?

Does your child have any missing or extra permanent teeth?

Has your child ever had an injury to (select all that apply)
Teeth
Mouth
Chin

Does your child have speech problems?

If so, explain

If yes, why?Does your child currently or has your child ever had any of the following habits (check all that apply)
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

Medical History

Is your child currently being treated by a physician?

If yes, why?

Physician

Date of Last Visit

Phone

Is your child currently taking any prescription or over-the-counter medications?

If yes, please list with the dosage

Has puberty and/or menstruation begun

Has your child had any serious illnesses or operations? If yes, describe

Has your child ever had a blood transfusion?

If yes, give approximate dates

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 child's medical status.

I hereby authorize the release of any information pertaining to my child's 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.

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Today's Date