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 Information

Patient's Name*
Current Gender Identification
Patient's Sex Assigned at Birth
MM slash DD slash YYYY
Street Address*
Ok to Leave a Message?*

Responsible Party Information

Responsible Party's Name*
Marital Status*
Relation to Child*
MM slash DD slash YYYY
Address
(If different than child)
Phone Type*
Phone Type

Insurance Information

Please provide all requested insurance information below.
MM slash DD slash YYYY
MM slash DD slash YYYY
How did you hear about our practice?*
Has your child ever visited an orthodontist before?*
Have we treated any other family members?*
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain or discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had any of the following injuries (select all that apply)?
Does your child have speech problems?
Does your child currently or has your child ever had any of the following (check all that apply)?
Is your child currently being treated by a physician?
MM slash DD slash YYYY
Does your child have any allergies and/or sensitivities to medications or latex??*
Is your child currently taking any prescription or over-the-counter medications?*
Has puberty and/or menstruation begun?*
Has your child ever had a blood transfusion?*
Please check if you have or have ever had any of the following:*

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.
Submitted by:*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.