Child New Patient Form
Patient Information
Patient Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone
*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Relationship to Patient
*
Who may we thank for referring you to Serrano Orthodontics?
Have we treated any additional family members?
Yes
No
If yes, please list their names
Parent/Guardian Information
Parents' Marital Status
*
Married
Single
Divorced
Separated
Widowed
Prefer not to answer
Parent/Guardian Type
*
Mother
Father
Other
Parent/Guardian's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security #
Home Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Email
example@example.com
Patient lives with:
*
Both Parents
Mother
Father
Other
Address (If Different than Patient's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation/Title
Work Phone
Please enter a valid phone number.
Number of Years at Current Job
Is this parent/guardian financially responsible for this account?
Yes
No
Second Parent/Guardian Information
Second Guardian Type
Mother
Father
Other
Relationship to Patient
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security #
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Address (If Different than Patient's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation/Title
Work Phone
Please enter a valid phone number.
Number of Years at Current Job
Dental Insurance Information
(If you have it)
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Owner's Name
First Name
Last Name
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Policy Owner's Employer
Group, Plan or Policy #
Member ID #
Secondary Dental Insurance
(If you have it)
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Owner's Name
First Name
Last Name
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Policy Owner's Employer
Group, Plan or Policy #
Member ID #
Medical Insurance
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Owner's Name
First Name
Last Name
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Policy Owner's Employer
Group, Plan or Policy #
Member ID #
Motivation for Treatment: The Teeth
If the child's teeth could be changed, how would you like them to change?
Make the upper front teeth
No Change
Longer
Shorter
Move upper teeth
No Change
Forward
Backward
Move lower teeth
No Change
Forward
Backward
Make the line of the upper teeth more level
No Change
Yes
No
Other
Please describe any other changes you would like to make with the child's teeth.
The Face
If the child's facial appearance could be changed, what would you change?
Get rid of sag under lower jaw
No Change
Yes
No
Move chin
No Change
Forward
Backward
Move chin to center it
No Change
Left
Right
Move lower lip
No Change
Forward
Backward
Move upper lip
No Change
Forward
Backward
Move the area around my nose
No Change
Forward
Backward
Make the profile of my nose
No Change
Longer
Shorter
Move the area under my eyes
No Change
Forward
Backward
Make my cheekbones
No Change
Larger
Smaller
When my teeth are touching, make my lips
No Change
Closer Together
Farther Apart
When my teeth are touching, make my lips not touch and roll out
No Change
Yes
No
Make my face more
No Change
Narrow
Wide
Reduce my lower jaw behind my mouth
No Change
Width
Fullness
Other
Please describe any other changes you would like to make with the child's face.
Symptoms
If you want to reduce pain or discomfort where is it located? Please be specific about the location; select right side, left side or both if they apply.
In front of my ears
None
Left
Right
Both
Below my ears
None
Left
Right
Both
Above my ears
None
Left
Right
Both
In my ears
None
Left
Right
Both
Neck
None
Left
Right
Both
Shoulders
None
Left
Right
Both
Temples
None
Left
Right
Both
Teeth
None
Left
Right
Both
Sinuses
None
Left
Right
Both
Eyes
None
Left
Right
Both
Other
Please describe any other symptoms you would like to treat.
Dental Information
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment your child receives from our office. This information is kept strictly confidential.
Does your child have a general dentist?
*
Yes
No
Dentist Name
Dentist Phone Number
Please enter a valid phone number.
When was your child's last dental cleaning?
*
Within last 3 months
Within last 6 months
Within last 12 months
Over 12 months ago
Exact date
Unknown
Does your child have any pending or planned dental work to be completed?
*
Yes
No
Did your child's dentist refer you to our office?
Yes
No
What is your main orthodontic concern for your child?
*
What are your thoughts or feelings about the possibility of orthodontic treatment?
Has your child ever had a previous orthodontic exam?
*
Yes
No
Has your child ever had previous orthodontic treatment?
*
Yes
No
Now, or in the past, has your child had issues with any of the following: (please check all that apply, or choose NONE)
*
Untreated cavities
Teeth extracted (baby or permanent)
Thumb or finger sucking habit
Impacted teeth
Sensitive or sore teeth
Supernumary (extra) teeth
Tooth grinding or clenching
Congenitally missing teeth
Mouth breathing
Bleeding gums
Snoring and/or sleep apnea
Gum disease
Tongue thrusting or sucking
Swelling or growths in the mouthLip biting
Problems eating, chewing, or swallowing
NONE
Does your child currently have any areas of irritation (pain, sores) in or around their mouth?
*
Yes
No
Has your child ever had any injury to their face, mouth, or teeth?
*
Yes
No
Does your child now, have they ever, experienced pain or discomfort in their jaw (i.e. TMJ/TMD issues)?
*
Yes
No
Medical Information
Is your child presently in good health?
*
Yes
No
Is your child currently under the care of a physician?
*
Yes
No
Does your child have a personal or family physician?
*
Yes
No
Is your child currently taking any prescription or non-prescription medications or supplements?
*
Yes
No
Does your child have any known allergies to any drugs or medications?
*
Yes
No
Does your child have any non-medication related allergies?
*
Yes
No
Has your child had any hospitalizations or major illnesses in the last 5 years?
*
Yes
No
Have your child's tonsils or adenoids been removed?
*
Yes
No
Does your child require antibiotic medicine prior to dental treatments?
*
Yes
No
Are there any learning disabilities or extra help needed for instructions?
*
Yes
No
Are there any other physical, mental, or medical issues we should be aware of?
*
Yes
No
Medical History
Now, or in the past, has your child had: (please check all that apply or choose NONE)
Asthma
Bone fractures
Blood pressure problems
Mental health disturbances
Birth defects/hereditary problems
Cancer/Chemotherapy
Arthritis/joint problems
Eating disorder
Seizures/neurological problems
Osteoperosis
Endocrine or thryoid problems
Diabetes
Bleeding problems
Mitral valve prolapse
Heart defects/disease
Kidney problems
Speech problems
Immune system problems
Frequent headaches or migraines
AIDS/HIV+
ADD/ADHD
Anemia
Bone disease
Tuberculosis
Thyroid or Endocrine problems
Artificial bones/joints
Drug or Alcohol Abuse
Heart attack
Heart murmur
Heart surgery/pacemaker
Congenital heart defect
Artificial heart valves
Blood transfusion
Ulcers
Stroke
Difficulty breathing
Liver disease
Psychiatric treatment
Glaucoma
Fainting spells
Venereal disease
NONE
Other
Privacy Notice
Insurance Release and Agreement
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company. I understand that I am responsible for payment of services rendered as well as any co-payments or deductibles.
Parent/Guardian Signature
*
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature/Verification of Information
I hereby state that I have read, understand and have truthfully, to the best of my ability answered all questions containted on this form. I will not hold my Orthodontist or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my Orthodontist of any changes in medical or dental health. I authorize the Orthodontist or their staff to perform any necessary dental services that I may need. I authorize this practice to share treatment with collaborating dentists, surgeons, or other professionals when appropriate.
Signature
*
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Location
Chandler Office
Phoenix Office
Click submit to securely send this form to our practice. Please note that further signatures may be required in the office.
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