Kincer CHILD New Patient Form

CHILD NEW PATIENT INFORMATION
We consider it a privilege to welcome you to our office. In an effort to provide the best treatment possible, we ask that you complete this form as completely as possible. We value your time and appreciate your cooperation.
LAST NAME
FIRST NAME
MIDDLE INITIAL
MAILING ADDRESS
BIRTH DATE

MonthDayYear
Date
Patient Gender
AGE
E-MAIL
example@example.com
HOME PHONE #
CELL PHONE #
CELL PHONE CARRIER (Verizon, AT&T, Sprint, etc)
SCHOOL
GRADE
GENERAL DENTIST
LAST DENTAL VISIT
Whom may we thank for referring you to our office?
PARENT / RESPONSIBLE PARTY (1)
LAST NAME
FIRST NAME
MIDDLE INITIAL
PARENT / RESPONSIBLE PARTY Gender
MAILING ADDRESS
BIRTH DATE

MonthDayYear
Date
E-MAIL
example@example.com
MARITAL STATUS
HOME PHONE #
CELL PHONE #
CELL PHONE CARRIER (Verizon, AT&T, Sprint, etc)
EMPLOYER
RELATIONSHIP TO PATIENT
PARENT / RESPONSIBLE PARTY (2)
LAST NAME
FIRST NAME
MIDDLE INITIAL
MAILING ADDRESS
BIRTH DATE

MonthDayYear
Date
E-MAIL
example@example.com
PARENT / RESPONSIBLE PARTY Gender
MARITAL STATUS
HOME PHONE #
CELL PHONE #
CELL PHONE CARRIER (Verizon, AT&T, Sprint, etc)
EMPLOYER
RELATIONSHIP TO PATIENT
PATIENT MEDICAL HISTORY
Is the patient under the care of a physician?

YesNo
If yes, please explain
Medical Physician
Phone
Has puberty begun for the patient?

YesNo
Has the patient ever been evaluated for orthodontic treatment?

YesNo
What are your main concerns regarding orthodontic treatment?
Has the patient had tonsils or adenoids removed?

YesNo
Has the patient ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo
Does the patient have any missing or extra permanent teeth?

YesNo
Has the patient ever had an injury to : (check all that apply)

TEETHMOUTHCHIN
Does the patient have any family members who have had orthodontic treatment?
Please check if the patient had, or currently has any of the following habits

Clenching / Grinding TeethLip Sucking / BitingMouth BreathingTongue ThrustingProlonged Bottle / PacifierNail BitingFinger / Thumb Sucking
Please check if you are allergic to any of the following.

AspirinErythromycinCodeinePenicillinTetracyclineLatexMetalsPlastics
Any other allergies/sensitivites?
Please list any drugs patient is currently taking and/or serious medical conditions.
I understand that the information that I have provided 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 this office of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor.
Parent / Responsible Party PRINTED Name
Patient Name
Parent Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

CHILD NEW PATIENT INFORMATION

PARENT / RESPONSIBLE PARTY (1)

PARENT / RESPONSIBLE PARTY (2)

PATIENT MEDICAL HISTORY