Child Form Please bring a copy of your insurance card, if available, to your initial consultation. Child Form Child registration form. "*" indicates required fields Patient InformationPatient's Name* First Last Patient's Preferred Pronouns Current Gender Identification Male Female Other Patient's Sex Assigned at Birth Male Female Birthday* MM slash DD slash YYYY Age Street Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone*Home PhoneOk to Leave a Message?* Yes No Email School Grade List any sports or extracurricular activitiesSiblings (names and ages)Responsible Party InformationResponsible Party's Name* First Last Marital Status* SIngle Married Divorced Widowed Significant Other Relation to Child* Mother Father Stepmother Stepfather Guardian Other Birthday* MM slash DD slash YYYY Address(If different than child) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Phone Type* Home Cell Secondary PhonePhone Type Home Cell Work Employer's Name* Occupation* Dental Insurance InformationPlease provide all requested dental insurance information below.Insurance Company Phone NumberGroup Number Member ID Number Policy Holder's Name Relation to Patient Policy Holder's Date of Birth MM slash DD slash YYYY Employer Work Phone NumberGeneral Dentist Last Visit MM slash DD slash YYYY How did you hear about our practice?* Invisalign Website Internet Family/Friend Dentist Other If Other, please tell how you heard about our practiceName of referring party (if applicable) What are the main concerns you would like orthodontics to correct?*Has your child ever visited an orthodontist before?* Yes No If yes, when and why? Have we treated any other family members?* Yes No If yes, who? Have your child's tonsils or adenoids been removed? Yes No Has your child ever experienced jaw joint pain or discomfort (TMJ/TMD)? Yes No Does your child have any missing or extra permanent teeth? Yes No Has your child ever had any of the following injuries (select all that apply)? Teeth Mouth Chin Does your child have speech problems? Yes No If yes, please explain? Does your child currently or has your child ever had any of the following (check all that apply)? Clenching/Grinding Teeth Snoring Mouth Breathing Thumb/Finger Sucking Special Blanket/Pillow/Stuffed Animal Pain/Tenderness in Jaw/TMJ/Headaches Tongue Thrust None/Not Applicable Is your child currently being treated by a physician? Yes No If yes, for what reason? Physician Last Visit MM slash DD slash YYYY PhoneDoes your child have any allergies and/or sensitivities to medications or latex??* Yes No If yes, please list them below:Is your child currently taking any prescription or over-the-counter medications?* Yes No If yes, please list them below with the dosage:Has puberty and/or menstruation begun?* Yes No Have you had any serious illnesses or operations? If yes, please describe:Has your child ever had a blood transfusion?* Yes No If yes, please give approximate dates:Please check if you have or have ever had any of the following:* ADD/ADHD Asthma Cancer Circulatory Problems Congenital heart Defect Diabetes Eating Disorder Epilepsy/Seizures Headaches Heart Murmur Hemophilia Hepatitis High Blood Pressure HIV/AIDS Kidney Disease Liver Disease Mental Health Issues Mitral Valve Prolapse Radiation Treatment Respiratory Disease Sinus Infections Substance Abuse Tonsilitis Tuberculosis Venereal Disease (STD) Other None If Other, please list below:AuthorizationI 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.Submitted by:* First Last Date* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. View the Adult Form
