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Child New Patient Intake Form

Child New Patient Form

"*" indicates required fields

MM slash DD slash YYYY
Child's Name*
Child's Home Address*
MM slash DD slash YYYY
Child's Gender
Child's Preferred Pronouns
Person accompanying child to appointment*
Does this person have legal custody of this child?*

Parental Information

Parent's Marital Status*
Mother/Partner/Guardian Information*
Mother/Partner/Guardian Name*
Mother/Partner/Guardian Email Address*
Would you like to receive email updates to this address?
Father/Partner/Guardian Information*
Father/Partner/Guardian Name*
Father/Partner/Guardian Email Address*
Would you like to receive email updates to this address?

Insurance / Billing Information

Person Responsible for Account*
Responsible Billing Party Address (if different from child's address)
INSURANCE – Do you have orthodontic coverage on your dental insurance policy? If no, skip insurance questions.*
Insurance Company Address
Policy Owner's Name
This is a secure site and all information will be kept strictly confidential.
MM slash DD slash YYYY
Employer's Address

Objectives and Patient Medical Information

Has your child ever been evaluated for orthodontic treatment before?*
Has your child ever had orthodontic treatment with a different orthodontist?*
Have adenoids or tonsils been removed?*
Has your child been informed of any missing or extra permanent teeth?*
Has your child ever had trauma to their teeth or been in an accident involving their teeth/mouth?*
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*
Does your child brush his/her teeth daily?*
Is your child currently under the care of a physician?*
Child's Physician
Please describe your child's current physical health:*
Allergic to Latex?*
Allergic to Metals/Nickel?*
Allergic to Plastics?*
Please check any of the following medical problems that your child has ever had:*
Please check any of the following that your child has ever experienced:*
This field is for validation purposes and should be left unchanged.
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