leggettorthodontics.com- Children Info

Hugh V.Leggett, Jr. DDS,MS Brent L.Leggett DDS, MS
Patient Name

First NameLast Name
Age
Birth Date

MonthDayYear
Sex
Patient’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent’s Name: Father

First NameLast Name
Parent’s Name: Mother

First NameLast Name
Father’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father’s Home Phone

Area CodePhone Number
Father’s Cell Phone
Mother’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Home Phone

Area CodePhone Number
Mother's Cell Phone
Person Responsible for Account

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is patient covered by dental insurance
Carrier Name
Primary Insured Name
SS#
DOB

MonthDayYear
Secondary Insured Name
SS#
DOB
Father’s Occupation
Employer
Work Phone

Area CodePhone Number
Mother’s Occupation
Employer
Work Phone

Area CodePhone Number
Who referred you to this office
Patient's General Dentist
Patient’s School
Grade
Does patient play a band instrument
Name of band instrument
Has any member of your family had orthodontic treatment
Orthodontist Name
Patient’s Interests and Hobbies
DENTAL HISTORY
Chief Oral Complaint
When was the last time you had a dental check up
Do you have any of the following? Indicate by check box:
Bleeding Gums?
How Long?
Oral habits:

Other
Unfavorable dental experience
Explain
Do you use any of the following by check the box:
How often do you Brush your Teeth:
How often do you Floss your Teeth:
MEDICAL HISTORY
Physician’s Name

First NameLast Name
Are you presently under a Physician’s Care?
What medicines is the patient currently taking?
Do you have or have you had any of the following? Indicate by check the box:
Pregnancy?
Delivery Date

MonthDayYear
Any other conditions
*If any change is the above information, please notify our office of change.
Signature
Should be Empty: