Pair Orthodontics Valencia Child

Orthodontics Acquaintance Card

About Your Child
Child's Full Name

First NameLast Name
Age & Nickname

AgeNickname (If Applicable)
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Phone Number

Area CodePhone Number
Owner of Best Phone Number (who we should ask for)

NameRelationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Special Interests, Sports or Hobbies
Who may we thank for sending you to our office?
Please list Siblings
ABOUT YOU
Father's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Phone #

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work

OccupationEmployer
Phone Numbers

Business Phone NumberCell Phone Number
Mother's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work

OccupationEmployer
Phone Numbers

Business Phone NumberCell Phone Number
Person Responsible for Account
Email of Responsible Party
IF YOU HAVE ORTHODONTICS INSURANCE, PLEASE COMPLETE INFORMATION BELOW:
DENTAL INSURANCE COMPANY #1
Name of Insurance Company
Their Phone Number

Area CodePhone Number
Group # and ID #

Group NumberID Number
Social Security #
This Dental Insurance is provided through:

Name of policy holderRelationship to Child
DENTAL INSURANCE COMPANY #2
Name of Insurance Company
Their Phone Number

Area CodePhone Number
Group # and ID #

Group NumberID Number
This Dental Insurance is provided through:

Name of policy holderRelationship to Child
Dental and Medical History:
Check the box if your child has ever had any of the following medical conditions or problems:
DOES YOUR CHILD NEED TO BE PREMEDICATED BEFORE DENTAL TREATMENT?
Are there any other medical conditions or problems relating to your child? If Yes, Explain.

Other
Is your child currently under the care of a physician? If so, please answer the following:

Name of PhysicianThe approx. date of last visit:Their Phone Number
IS YOUR CHILD ALLERGIC TO ANY DRUGS?
If Yes, please list all allergies separated by a comma.
Is your child taking any prescription drugs?
If Yes, please list all drugs currently being taken.
Is your child currently under the care of a dentist? If so, please answer the following:

Name of PhysicianThe approx. date of last visit:Their Phone Number
Have there been any injuries to the face, mouth or teeth?
Has your child had tongue thrust or speech therapy?
Does your child have any speech problems?
Have you ever been informed of any missing or extra teeth?
Does your child’s jaw ever crack or pop sound when chewing or yawning?
Have you been told your child has TMJ (Temporomandibular Joint) problems?
Is your child a mouth breather?
Has your child’s jaw ever locked open?
Has an orthodontist been consulted previously?

Other
Has your child ever sucked his/her thumb or fingers?

Other
WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH?
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 confidence, and it is my responsibility to inform this officeof any changes in my child’s medical status.
Sign below:
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: