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New_patient_form_child

Who may we thank for referring you? _________________________________________________________________ Tell us About Your Child
Child’s Name: ___________________________________________________________________________________ First Preferred Name: __________________________ Hobbies / Sports: _________________________________________________________________________________ Home Address: __________________________________________________________________________________ ________________________________________________________________________________________________ City State Zip General Dentist: ________________________________ Last Visit Date: _________________________ *If you do not have a general dentist as this time please be considering potential dentists for your child’s general care as this will be necessary during their orthodontic treatment.
Mother’s Information
Name: ____________________________________ Birthdate: _____________________________ Home #: _________________ Work #: __________________ Employer:_____________________________ Father’s Information
Name: ____________________________________ Birthdate: ______________________________ Home #: __________________ Work #: __________________ Employer: ______________________________ Person Responsible For Account
Name: _________________________________________ Billing Address: _________________________________________________________________________________ __________________________________________________________________________________ Home # (if different): _________________ Work # (if different): ______________________ Email address;____________________________________________ Dental Insurance Information
Insurance Co. Name: ___________________________________________________ Insurance Co. Address: __________________________________________________ __________________________________________________ Insurance Co. Phone#: ___________________________________________________ Group # (Plan# or Policy#): ________________________________________________ Policy Owner’s Name: ___________________________________________________ Policy Owner’s Birthdate: __________________ SS#: ________________________ Policy Owner’s Employer: ________________________________________________ Secondary Dental Insurance Information
Insurance Co. Name: ___________________________________________________ Insurance Co. Address: __________________________________________________ __________________________________________________ Insurance Co. Phone#: ___________________________________________________ Group # (Plan# or Policy#): ________________________________________________ Policy Owner’s Name: ___________________________________________________ Policy Owner’s Birthdate: __________________ SS#: ________________________ Policy Owner’s Employer: ________________________________________________ Patient Medical History Information
Please describe your child’s physical health: (circle one) Good Fair Poor
Please list any conditions for which your child is currently under a physician’s care _____________________________ ________________________________________________________________________________________________ Child’s Physician ______________________________Ph#________________________________________________ Has your child ever taken Phen-Fen or a bisphosphonate medication, including Fosamax, Zometa, Aredia, Didronel,
Actonel, Skelid, or Boniva? Y or N

Please list any drugs that your child is currently taking? __________________________________________________ Has your child ever taken antibiotics prior to dental care? _________________________________________________ Has puberty begun? Y or N Has menstruation begun? (Girls) Y or N
Has your child ever had any of the following medical problems?
Please describe any health issues not listed above and the reason for any surgeries or hospital stays: ________________________________________________________________________ Is your child allergic to any of the following?
Please list any other drugs/materials that your child is allergic to:____________________________________________ Patient Dental History Information
What is your main concern about your smile/teeth? ______________________________________ Has your child ever been evaluated for or had orthodontic treatment? Y or N
If yes, what appliances were used? _____________________________________________ When were they begun and finished? _________________________________ Have there been any injuries to the: Mouth
Chin (please circle) At what age?________________
What was the accident? _________________________________________________ Have adenoids or tonsils been removed? Y or N At what age? _________________________________
For what reason? _______________________________________________________ Has your child been informed of any missing or extra permanent teeth? Missing or Extra
Are you aware of any clenching or grinding of the teeth? Any history of thumb/finger sucking beyond age 4? Any other oral habits (i.e. pen chewing, fingernail biting, etc.)? Have you ever been told your child has a tongue thrust? Patient TMJ History Information
Does your child now or has he/she ever experienced pain/discomfort in the jaw joint/TMJ? Y or N
Please describe___________________________________________________________________________________ How often?_________________________How many months/yrs.?__________________________________________ Do they have frequent headaches on the sides of their head? How often?______________How many months/yrs.?___ Do they have frequent pain in the neck or shoulders? How often?____________________How many months/yrs.?___ Have they ever been in a car accident or other traumatic incident that resulted in a blow to the face or neck? Please describe & date of occurence________________________________________________________________________ Have they ever been given or purchased a nightguard or splint for sleeping? I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform Cain Orthodontics of any change in my child’s medical status. I authorize the Orthodontic staff to perform the necessary orthodontic services my child may need.
__________________________________________

Source: http://deadwoodlab.com/drcain/wp-content/uploads/downpdf/New-Patient-Form-Child.pdf

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