Child Patient Form

Child Registration Form - Ortho
* required field

Patient Information







Primary Phone Number

Parent/Guardian Information

Parents' Marital Status



Phone Number
Secondary Phone Number
Untitled







Phone
Secondary Phone Number

Emergency Contact









Insurance Information






















Dental History

How did you hear about our Practice?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Has your child ever had an injury to (select all that apply):
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?



Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has your child had any serious illnesses or operations? If yes, describe:
Check if your child has 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 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.