Child New Patient Information Form

Child New Patient Information

Patient Information

Patient Name:

Gender:

Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type:

home cell

E-mail:

School:

Grade:

Parent 1

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type:

home cell

Parent 2

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type:

home cell

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

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's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Last Visit & Referral

Last Visit Date:

How did you hear about our practice?

Ad Internet Family/Friend Physician Other

Name of person referring (if applicable):

Medical/Dental Information

Has your child visited an orthodontist before?

Yes No

If yes, when?:

Reason:

Have we treated any other family members?

Yes No

Name:

Has your child's tonsils or adenoids been removed?

Yes No

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

Yes No

Does your child have any missing or extra permanent teeth?

Yes No

Has your child ever had an injury to (select all that apply):

Teeth Mouth Chin

Does your child have speech problems?

Yes No

If so, explain:

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

Has your child ever had or been treated for any of the following?

Asthma

Yes No

Diabetes

Yes No

Epilepsy/Seizures

Yes No

Heart Problem

Yes No

Anemia

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

Kidney Problems

Yes No

Rheumatic Fever

Yes No

Cancer

Yes No

Allergies

Yes No

Thyroid Problems

Yes No

Other Medical Conditions:

Child's Physician:

Child's Dentist:

Current Medications:

Authorization

I have read and completed this form in its entirety and to the best of my knowledge it is correct. I authorize Gibson Orthodontics to perform diagnostic procedures and provide dental treatment for my child.

I have read and agree to the above statement.

Signature:

Date: