Child New Patient Intake Form Georgetown Orthodontics

Child New Patient Form

"*" indicates required fields

Today's Date

Child's Name*

First Middle Last

Name child prefers to be called

Child's Home Address*

Street Address Address Line 2 City State ZIP Code

Child's Birth Date*

Child's Age*

Child's Gender

Male

Female

Child's School

Child's Grade

Child's Hobbies / Sports

Person accompanying child to appointment*

First Last

Relation to the Child*

Email Address*

Does this person have legal custody of this child?*

Yes

Whom may we thank for referring you?

List brothers / sisters with ages:

General Dentist Name*

Last Visit date to Dentist (approximate)*

Parental Information

Parent's Marital Status*

Mother/Partner/Guardian Information*

Mother

Stepmother

Partner

Guardian

Mother/Partner/Guardian Name*

First Last

Mother/Partner/Guardian Email Address*

Enter Email Confirm Email

Would you like to receive email updates and appointment reminders to this address?

Yes

Mother/Partner/Guardian Cell Phone Number*

Would you like to receive text updates and appointment reminders to this number?

Yes

Mother/Partner/Guardian Home Phone Number

Mother/Partner/Guardian Employer*

Mother/Partner/Guardian Work Phone Number

Father/Partner/Guardian Information

Father

Stepfather

Partner

Guardian

Father/Partner/Guardian Name

First Last

Father/Partner/Guardian Email Address

Enter Email Confirm Email

Would you like to receive email updates and appointment reminders to this address?

Yes

Father/Partner/Guardian Cell Phone Number

Would you like to receive text updates and appointment reminders to this number?

Yes

Father/Partner/Guardian Home Phone Number

Father/Partner/Guardian Employer

Father/Partner/Guardian Work Phone Number

Insurance / Billing Information

Person Responsible for Account*

First Last

Relation to Child*

Responsible Billing Party Address (if different from child's address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

INSURANCE – Do you have orthodontic coverage on your dental insurance policy? If no, skip insurance questions.*

Yes

Insurance Company Name

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Insurance Company Phone Number

Group Number (Plan, Local or Policy #)

ID#

Policy Owner's Name

First Last

Relationship to Patient

Policy Owner's Social Security Number (required to file some insurances)

This is a secure site and all information will be kept strictly confidential.

Policy Owner's Birthdate

Policy Owner's Employer

Employer's Address

Street Address Address Line 2 City State ZIP Code

Objectives and Patient Medical Information

What are the main concerns that you would like orthodontics to accomplish?*

Has your child ever been evaluated for orthodontic treatment before?*

Yes

Has your child ever had orthodontic treatment with a different orthodontist?*

Yes

If your child has had previous orthodontic treatment please list the type of treatment, approximate dates of treatment, and the Orthodontist's name

Have adenoids or tonsils been removed?*

Yes

Has your child been informed of any missing or extra permanent teeth?*

Yes

Has your child ever had trauma to their teeth or been in an accident involving their teeth/mouth?*

Yes

If you answered yes, please give a brief description:

Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

Yes

Does your child brush his/her teeth daily?*

Yes

Is your child currently under the care of a physician?*

Yes

Child's Physician

First Last

Physician's Phone Number

Date of Last Visit (approximate)

Please describe your child's current physical health:*

Good

Fair

Poor

Please list all prescribed and over the counter medications that your child is currently taking:*

Please list any medication and/or food allergies:*

Allergic to Latex?*

Yes

Allergic to Metals/Nickel?*

Yes

Allergic to Plastics?*

Yes

Please check any of the following medical problems that your child has ever had:*

Please discuss any medical problems that your child has had:

Please check any of the following that your child has ever experienced:*

Clenching / Grinding Teeth

Lip Sucking / Biting

Mouth Breather

Nail Biting

Nursing Bottle Habits

Speech Problems

Thumb / Finger Sucking

Tongue Thrust

None

Notice of Privacy Practices*

Your trust and privacy are paramount to us as we strive to provide exceptional dental services. This privacy policy is designed to inform you about how we handle personal information collected through our website and in-office: We collect information that you choose to provide to us through emails or direct contact. This information is under our sole ownership and is never sold or distributed. We utilize your information primarily to respond to your inquiries and fulfill your requests, ensuring you receive top-notch dental care. We only share your information with entities outside our organization when necessary to deliver these services or as required by law. With your consent, we may occasionally inform you about our special offers, new products or services, or changes to this privacy policy. You have the right to restrict how your protected health information is used and disclosed. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: A. Protected health information may be disclosed or used for treatment, payment, or healthcare operations. B. The practice reserves the right to change the privacy policy as allowed by law. C. The patient/legal guardian has the right to restrict the use of the information and shall inform the office in writing as to what PHI they wish to restrict, if applicable. D. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

I understand that the information that I have given 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 child's medical status.*

Comments

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Additional Topics

Child New Patient Intake Form

Child New Patient Form

Parental Information

Insurance / Billing Information

Objectives and Patient Medical Information