Adolescent Intake
Welcome to the orthodontist
1. Tell us about your child
Today's date
/
Month
/
Day
Year
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Your child's name
*
First Name
MI
Last Name
E-mail
Child's Birthdate
*
-
Month
-
Day
Year
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Gender
*
Male
Female
How old is your child?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade
Child's Home #
*
-
Area Code
Phone Number
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2. Who is accompanying your child today?
Name
*
First Name
Last Name
Relation
*
Do you have legal custody of this child?
*
Yes
No
Whom we may thank for referring you?
*
General Dentist
*
Last visit date
List brothers / sisters with age
Parent's marital status
Single
Married
Partnered
Separated
Divorced
Widowed
Other
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3. Parents
Parent
Mother
Father
Step Parent
Guardian
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
E-mail
Phone Number
-
Area Code
Phone Number
Employer
Parent
Mother
Father
Step Parent
Guardian
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
E-mail
Phone Number
-
Area Code
Phone Number
Employer
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4. Person responsible for account
Name
*
First Name
Last Name
Relation
*
Address same as above
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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5. Primary orthodontic insurance
Orthodontic coverage
*
Yes
No
Insurance company name
*
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
-
Area Code
Phone Number
Group #
Policy #
*
Policy owner's Name
*
First Name
Last Name
Relationship to the patient
*
Policy owner birthdate
-
Month
-
Day
Year
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Policy owner's employer
Employer's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Orthodontic Insurance
Orthodontic coverage
Yes
No
Insurance company name
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
-
Area Code
Phone Number
Group #
Policy #
Policy owner's Name
First Name
Last Name
Relationship to the patient
Policy owner birthdate
-
Month
-
Day
Year
Date Picker Icon
Policy owner's employer
Employer's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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6. What are the main concerns that you would like orthodontics to accomplish?
*
Has your child ever been prescribed Fosamax or any other bisphosphonate?
*
Yes
No
If yes, when?
Has your child ever been evaluated or had orthodontic treatment before?
*
Yes
No
Have there been any injuries to the face, mouth, teeth, or chin?
*
Yes
No
Have adenoid or tonsils removed?
*
Yes
No
Has your child ever been informed of any missing teeth or extra permanent teeth?
*
Yes
No
Has your child ever had pain / tenderness in his / her jaw joint (TMJ / TMD)?
*
Yes
No
Does your child brush teeth daily?
*
Yes
No
Child's Physician
Phone Number
-
Area Code
Phone Number
Date of last visit
-
Month
-
Day
Year
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Is your child currently under care of a physician
*
Yes
No
Has puberty begun?
*
Yes
No
Has menstruation begun?
Yes
No
Please describe child's health
*
Good
Fair
Poor
Please list all drugs your child is currently taking
*
Please list all drugs / things your child is allergic to
*
Allergies to
*
Rows
Yes
No
Latex
Metals/Nickel
Plastics
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7. Has your child ever had any of the following medical problem?
*
Rows
Yes
No
Abnormal bleeding
Add/ADHD
Any hospital stays
Any operations
Artificial bones / joints
valves
Asperger syndrome
Asthma
Autism
Cancer
Congenital heart defect
*
Rows
Yes
No
Convulsions/epilepsy
Diabetes
Handicaps/disabilities
Hearing impairment
Heart murmur
Hepatitis
HIV/AIDS
Kidney/liver problems
Lupus
Rheumatic/scarlet fever
Tuberculosis (TB)
Please discuss any medical problems that your child has had
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8. Has your child ever experienced any of the following?
*
Rows
Yes
No
Clenching/grinding teeth
Lip sucking/biting
Mouth breather
Nail biting
*
Rows
Yes
No
Nursing bottle habits
Speech problems
Thumb/finger sucking
Tongue thrust
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9. 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 any changes in my child's medical status
The parent or guardian who accompanies the child is responsible for payment. Our office is HIPAA compliant and is committed to meeting or exceeding the standards infection control mandated by OSHA, the CDC, and the ADA.
I authorize the dental staff to perform the necessary dental services my child may need.
*
This office reserves the right to verify the credit status of potential patients' and/or parents of patients prior to extending credit for treatment fee and may, at discretion of this office, use the services of one or more credit reporting services.
*
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
*
Date
-
Month
-
Day
Year
Date Picker Icon
Submit
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