Child New Patient Form

suwaneeorthodontics.com - Child Registration Form

Patient Information

*Gender:
 
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*Phone Type
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Parent / Guardian Information

Parent 1

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*Marital Status
*Relation to Child:
 
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*Phone Type:
Phone Type:
 

Parent 2

Marital Status
Relation to Child::
 
 
Phone Type:
Phone Type:
 

Emergency Contact Information

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Insurance Information

Primary Insurance

 

Secondary Insurance

 

Dental History

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*How did you hear about our practice?
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Has your child visited an orthodontist before?
*Have we treated any other family members?
*Have your child's tonsils or adenoids been removed?
*Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
*Does your child have any missing or extra permanent teeth?
*Has your child ever had an injury to (select all that apply):
*Does your child have speech problems?
*Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

*Is your child currently being treated by a physician?
*Do you have any allergies/sensitivities to medications or latex?
*Is your child currently taking any prescription or over-the-counter medications?
*Has puberty and/or menstruation begun?
*Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

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Security Measure