Child New Patient Registration

Child New Patient Registration

Confidential
How did you hear about our office?*
Referring Dentist
Who may we thank for referring you?
If other, please state:
Patient Full Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Parent/Guardian Cell Phone Number
Parent/Guardian E-mail
example@example.com
Home Address*
School Name
Grade
Hobbies
Parent/Guardian 1*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
How would you like to receive appointment reminders?

Text MessageEmail
Check the Appropriate Box*

FatherMotherGaurdianStep Father/MotherOther
Parent/Gaurdian 1 Marital Status*
Parent/Guardian 2 (If none, type NONE)
Phone Number*

Area CodePhone Number
Email*
example@example.com
How would you like to receive appointment reminders?

Text MessageEmail
Check the Appropriate Box*

FatherMotherGaurdianStep Father/MotherOther
Parent/Gaurdian 2 Marital Status*
Will you be using your dental insurance for your child?*

YesNo
Insurance Subscriber's Information
Insurance Company*
Subscriber Name*

First NameLast Name
Social Security Number
(This may be required in order to verify eligibility and benefits)
Subscriber ID Number*
Subscriber Birth Date*

MonthDayYear
Please upload pictures of your dental insurance card, both front and back

Browse Files

Cancelof
Medical History
Patient's Physician:
Phone Number
Last check-up date:
MM/YYYY

Please indicate if you have any of the following condition:*

Are you currently under care of a physician?
Please indicate any allergies, or significant medical history that we need to be aware of.*
(N/A if Not Applicable)
Dental History
Patient's General Dentist or Children's Dentist:*
Phone Number*
Last check-up date:*
MM/YYYY

Please fill out the following:

	Yes	No
Do you have any outstanding dental work to be completed?
Have you had any previous orthodontic treatment?
Has any of your family had orthodontic treatment?
Do you have any missing teeth?
Do you have any problem with eating or chewing?
Have you had any teeth removed?
Have you had any injury to your face, jaws, or teeth?
Are you currently experiencing any dental or facial pain?
Do you grind your teeth at night?
Do you snore at night?

Please indicate any dental history that we need to be aware of.*
(N/A if Not Applicable)
What is your main concern for bringing your child to our office?*
How interested are you in starting treatment within the next month? (1 lowest to 10 highest)*
What type of treatment option interests you? (Choose all that apply)*

InvisalignInBrace (Hidden braces behind your teeth)Clear bracesMetal braces
Which is the most desirable option?*
What is important when choosing a treatment?*

Length of the treatmentComfort during treatmentTreatment using the latest technologyClear/ invisible treatment technologyA low down paymentA low monthly paymentQuality of treatment
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to the patient’s health. It is my responsibility to inform Dr. Shin of any changes in medical and/or dental status. I also authorize Dr. Shin, and staff to perform all the necessary procedures deemed appropriate to make a thorough diagnosis of the patient’s dental and oral facial needs.
Parent/Gaurdian Signature (If Patient is under 18)*

Clear
Please Print Name*

First NameLast Name
Relationship to the Patient:*
Today's Date:*
Want to learn more about treatment options? Click on the links below!

Welcome to Shin Orthodontics!

InBrace: (Hidden braces behind your teeth)

Invisalign Teen

Invisalign First for kids!

Metal braces
Should be Empty:

Insurance Subscriber's Information