Adolescent Intake

Adolescent Intake
Welcome to the orthodontist
1. Tell us about your child
Today's date

/ Month / Day Year
Your child's name *

First Name MI Last Name
E-mail
Child's Birthdate *

- Month - Day Year
Gender *

Male Female
How old is your child? *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Grade
Child's Home # *

- Area Code Phone Number

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

3. Parents
Parent

Mother Father Step Parent Guardian
Name *

First Name Last Name
Birth Date *

- Month - Day Year
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
E-mail
Phone Number

- Area Code Phone Number
Employer

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	Country

Phone Number

- Area Code Phone Number

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	Country

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
Policy owner's employer

Employer's address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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	Country

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
Policy owner's employer

Employer's address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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. *

Clear
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. *

Clear
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. *

Clear
Date

- Month - Day Year
Should be Empty:

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