Child

Child New Patient Information

Patient Information

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Parent/Guardian Information

Parent Marital StatusSingleMarriedDivorcedWidowedSignificant Other
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Relationship

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Emergency Contact

Insurance Information

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Dental History

How did you hear about our Practice?AdInternetFamily or FriendPhysicianOther
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?YesNo
Has your child's tonsils or adenoids been removed? YesNo
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? YesNo
Does your child you have any missing or extra permanent teeth? YesNo
Has your child ever had an injury to (select all that apply):TeethMouthChin
Does your child have speech problems? YesNo
Does your child currently or has your child ever had any of the following habits?Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems

Medical History

Is your child currently being treated by a physician? YesNo
Does your child have any allergies/sensitivities to medications or latex? YesNo
Is your child currently taking any prescription or over-the-counter medications? YesNo
Has puberty and/or menstruation begun? YesNoN/A
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? YesNoN/A
Has your child ever had a blood transfusion? YesNo
Is your child pregnant? YesNo
Nursing? YesNo
Taking birth control pills? YesNo
Check if your child has or have ever had any of the following:
AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

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 medical status. I hereby authorize the release of any information pertaining to my 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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Dear Patients,

We have always been at the leading edge of infection control & follow all the CDC, ADA, and AAO guidelines. Our highest priority is keeping all patients and team members safe. Your health and safety is our highest priority.

Sincerely,
Dr. Mendez and the team at All About Smiles Orthodontics