PATIENT INFORMATION:

First Name:*

Last Name:*

Gender:*
MaleFemale

Date of Birth:*

Address:*

City:*

Postal code:*

Home Phone:*

Cell Phone:*

Email:*

Best Time To Call:

School:

Family Dentist:

How did you hear about our office?
DentistNewspaperInternetFriendsOther

Dentist/Other:

PARENTS / RESPONSIBLE PARTY (IF NOT PARENT)

Parent I

Name:

Relationship with patient:

Occupation:

Contact #:

Email:

Dental Insurance

Do you have DENTAL INSURANCE that covers orthodontic treatment?
yesno

Insurance company:

Employer:

Date of Birth:

Subscriber ID/Certificate #:

Group/Policy #:

Coverage:

Parent II

Name:

Relationship with patient:

Occupation:

Contact #:

Email:

Dental Insurance

Do you have DENTAL INSURANCE that covers orthodontic treatment?
yesno

Insurance company:

Employer:

Date of Birth:

Subscriber ID/Certificate #:

Group/Policy #:

Coverage:

Dental / Medical History

Is your child in good general health? YesNo

Has your child had any serious chronic illnesses or operations? YesNo

How long ago was your child’s last visit to a dentist?

Does your child require pre­-medication before dental work? If yes, what condition is this for? YesNo

Is your child taking any medications? Please list:

Does your child have a history of:Heart problemsAllergiesDiabetesAsthmaFaintingArthritisHepatitisRheumatic feverThumb/finger suckingNail bitingSnoringMouth breathing

Does your child experience:
Difficulty opening the mouth / ‘Popping’ or ‘clicking’ noises from the jaw jointsPain around the ears or cheek / Pain on opening wide, chewing or yawningLocked or dislocated jaw

Has your child ever had injury to:
jawteethmouthheadneck

Does his/her bite feel uncomfortable or unusual? YesNo

Has your child been treated for TMJ (Temporomandibular disorder)? YesNo

Is he/she under any stress? YesNo

Is there any other health information that we should know about?

Have you consulted with another orthodontist?
YesNo

Has he/she had any previous orthodontic treatment? YesNo

If yes, please explain:

Last radiograph taken (Panoramic X­ray):

If you answered to yes for any of the above, please explain: