New Patient Forms (Child)

Patient Full Name *

First

Middle

Last

Gender *

Male
Female

Birth Date *

Age

Primary Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

School

Grade

Please list any sports or extracurricular activities

Please list any siblings (names and ages)

Parent/Guardian Marital Status

Single
Married
Divorced
Widowed
Significant Other

Relationship to Patient *

Parent/Guardian Name *

First

Last

Parent/Guardian Birth Date

Parent/Guardian Social Security Number

Parent/Guardian Address

Same as Patient

Parent/Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Primary Phone Number *

Parent/Guardian Secondary Phone Number

Employer

Occupation

Emergency Contact Name (other than person listed above) *

First

Last

Emergency Contact Primary Phone Number *

Emergency Contact's Relation to Patient

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Please list the names of anyone authorized to receive appointment and medical information related to the patient

Relationship to patient

Primary Insurance Company *

Insurance Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

First

Last

Policy Holder's Relationship to Patient

Policy Holder's Birth Date

Policy Holder's Social Security Number

Policy Holder's Employer

Policy Holder's Work Phone Number

Does the Patient Have Secondary Insurance?

Secondary Insurance Company

Secondary Insurance Phone Number

Secondary Insurance Group Number

Secondary Insurance Policy Number

Secondary Insurance Member ID Number

Secondary Insurance Policy Holder's Name

First

Last

Secondary Insurance Policy Holder's Relationship to Patient

Secondary Insurance Policy Holder's Birth Date

Secondary Insurance Policy Holder's Social Security Number

Secondary Insurance Policy Holder's Employer

Secondary Insurance Policy Holder's Work Phone Number

How did you hear about our practice?

Ad
Internet Search
Family or Friend
Physician
Other

Name of person referring (if applicable)

Have your child's 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 yes, please explain

Does your child have or has your child ever had any of the following habits?

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problems

Is your child currently being treated by a physician? *

Physician Name

First

Last

Physician Phone

Date of Last Visit

Reason for Physician Visit

Does your child have any allergies/sensitivities to medications or latex?

If yes, please list allergies

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

Please list any medications taken, along with dosage

Has puberty and/or menstruation begun?

Yes
No
Not applicable

Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

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

Has your child ever had a blood transfusion?

If yes, give approximate dates:

Is your child pregnant?

Is your child nursing?

Is your child taking hormonal birth control?

Check if your child has or has ever had any of the following:

Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease

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.

Patient Signature and/or Responsible Party *

Today's Date *

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