RJ Orthodontics - Child Registration

New Child Patient: Secure Registration Form

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank You!
Patient Name

First NameLast Name
Social Security Number
Gender

MaleFemale
Birth Date

MonthDayYear
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Ok to leave message?

YesNo
E-mail
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Parents Marital Status

SingleMarriedDivorcedWidowedSignificant OtherOther
Choose One

MotherStep-MotherGuardianOther
Name

First NameLast Name
Social Security Number
Birth Date

MonthDayYear
Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Employer's Name
Occupation
Choose One

FatherStep-FatherGuardianOther
Name

First NameLast Name
Social Security Number
Birth Date

MonthDayYear
Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Employer's Name
Occupation
How did you hear about our practice?

AdInternetFamily/FriendPhysicianOther
Name of Person referring ( if applicable)

First NameLast Name
Insurance Information
Primary Dental Insurance Company
Phone Number

Area CodePhone Number
Group Number
Policy Number
Policy Holder's Name

First NameLast Name
Relation
Policy Holder's Social Security Number
Policy Holder's Date Of Birth

MonthDayYear
Employer
Work Phone Number

Area CodePhone Number
Deductible (if known)
Co-Pay (if known)
Secondary Dental Insurance Company
Phone Number

Area CodePhone Number
Group Number
Policy Number
Policy Holder's Name

First NameLast Name
Relation
Policy Holder's Social Security Number
Employer
Phone Number

Area CodePhone Number
Deductible (if known)
Co-Pay (if known)
Health History
General Dentist
Last Visit
Has your child visited an orthodontist before?

YesNo
If so when?

MonthDayYear
Reason
Have we treated any other family members?

YesNo
If so, What is their Name?

First NameLast Name
Have your child's tonsils or adenoids been removed?

YesNo
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo
Does your child have any missing or extra permanent teeth?

YesNo
Does your child have speech problems?

YesNo
If so, explain
Has your child ever had an injury to (select all that apply)

TeethMouthChin
Does your child currently or have you ever had any of the following habits (check all that apply)

Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating Problem
Is your child currently being treated by a physician?

YesNo
Reason
Physician
Date of Last Visit

MonthDayYear
Phone Number

Area CodePhone Number
Does your child have any allergies/sensitivities to medications or latex?

YesNo
If Yes, please list them
Is your child currently taking any prescription or over the counter medications?

YesNo
If Yes, please list with dosage
Has puberty and/or menstruation begun?

YesNoN/A
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.
Submitted By:
Parent/Guardian Full Name
Date

MonthDayYear
Enter the message as it's shown*
Should be Empty:

Insurance Information

Health History