Patient Name
    Address
    Town
    Zip Code
    Gender
    MaleFemale
    Home Phone
    Email Address
    Who Referred You?
    School
    Grade
    Birth Date
    Birthplace
    Dentist's Name
    Date Of Last Checkup
    Physician's Name
    Date Of Last Checkup
    Father's Name
    Mother's Name
    Father's Date Of Birth
    Mother's Date Of Birth
    Father's Social Security
    Mother's Social Security
    Father's Employer
    Mother's Employer
    Father's Work Phone
    Father's Cell Phone
    Mother's Work Phone
    Mother's Cell Phone
    Parent's Marital Status
    MarriedDivorcedWidowedSeparatedSingle
    Are Any Family Members Currently In Treatment?
    YesNo
    If So, Why?
    Currently Wearing Braces?
    YesNo
    Currently Wearing Retainers?
    YesNo
    Has An Appliance?
    YesNo
    Invisalign?
    YesNo
    Waiting To Begin Treatment?
    YesNo
    1. What Are The Main Concerns That You Would Like Orthodontics To Accomplish For Your Child?
    2. Is Your Child In Good Health?
    YesNo
    3. Does Your Child Have Regular Medical Examinations?
    YesNo
    4. Has Your Child Ever Had Any Of The Following? (Please Check)
    Allergies To Any Drugs?
    5. Does your child require pre-medication for any condition, If so, What?
    6. Is there anything else we should know about your child’s general health? Such as allergies to medications, food, Latex, etc
    7. Has your child ever had any injuries to the face, mouth, teeth, or chin? If yes, please explain
    8. Is your child a mouth-breather or thumb sucker? If yes, please explain
    9. Is there a hereditary background that might contribute to your child’s dental problem
    YesNo
    10. Has your child ever had any pain / tenderness in their jaw joint (TMJ)?
    YesNo
    11. Other Remarks
    12. Please indicate any medications that your child is currently taking
    13. Do you have any Orthodontic Dental Insurance?
    14. Name Of Dental Insurance Company?
    By entering your initials, you are providing your signature electronically.