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Georgetown, TX
(512) 872-4200
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Menu
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Why Choose Us
First Visit
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FAQ
New Patient Intake Forms
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All About Braces
Common Problems
Braces 101
Early Orthodontics
Adolescent Treatment
Adult Orthodontics
Clarity Braces
Orthodontic Retainers
Invisalign
Invisalign
Invisalign Teen
Cost of Invisalign
Contact Us
Office Hours & Location
Request an Appointment
Emergency Care
Menu
Braces 101
Early Orthodontics
Adolescent Treatment
Adult Orthodontics
Clarity Braces
Orthodontic Retainers
Invisalign
Invisalign
Invisalign Teen
Cost of Invisalign
Contact Us
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Request an Appointment
Emergency Care
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Child New Patient Intake Form
Child New Patient Form
"
*
" indicates required fields
Today's Date
MM slash DD slash YYYY
Child's Name
*
First
Middle
Last
Name child prefers to be called
Child's Home Address
*
Street Address
Address Line 2
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Child's Birth Date
*
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Child's Age
*
Child's Gender
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Child's Preferred Pronouns
She/Her
They/Them
He/Him
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
No
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
*
Single
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Mother/Partner/Guardian Information
*
Mother
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*
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Mother/Partner/Guardian Email Address
*
Enter Email
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Mother/Partner/Guardian Cell Phone Number
*
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
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No
Father/Partner/Guardian Cell Phone Number
*
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
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City
State / Province / Region
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Country
INSURANCE – Do you have orthodontic coverage on your dental insurance policy? If no, skip insurance questions.
*
Yes
No
Insurance Company Name
Insurance Company Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
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California
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Delaware
District of Columbia
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Northern Mariana Islands
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Tennessee
Texas
Utah
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Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
MM slash DD slash YYYY
Policy Owner's Employer
Employer's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
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California
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District of Columbia
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Kentucky
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Maine
Maryland
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Michigan
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Montana
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New Hampshire
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New York
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North Dakota
Northern Mariana Islands
Ohio
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Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
No
Has your child ever had orthodontic treatment with a different orthodontist?
*
Yes
No
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
No
Has your child been informed of any missing or extra permanent teeth?
*
Yes
No
Has your child ever had trauma to their teeth or been in an accident involving their teeth/mouth?
*
Yes
No
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
No
Does your child brush his/her teeth daily?
*
Yes
No
Is your child currently under the care of a physician?
*
Yes
No
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
No
Allergic to Metals/Nickel?
*
Yes
No
Allergic to Plastics?
*
Yes
No
Please check any of the following medical problems that your child has ever had:
*
Abnormal Bleeding
ADD / ADHD
Allergies to any Drugs
Allergic to Latex
Allergic to Metal
Allergic to Plastic
Any Hospital Stays
Any Operations
Artificial Bones / Joints / Valves
Asthma
Cancer
Congenital Heart Defect
Convulsions / Epilepsy
Diabetes
Handicaps / Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+ / AIDS
Kidney / Liver Problems
Lupus
Rheumatic / Scarlet Fever
Tuberculosis (TB)
None
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
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.
*
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