Pair Orthodontics Northridge Child

Orthodontics Acquaintance Card

About Your Child
Child's Full Name *

First Name Last Name
Age & Nickname *

Age Nickname (If Applicable)
Child's Date of Birth

Month Day Year
Date
Best Phone Number

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

Name Relationship
Address

Street Address

Street Address Line 2

City State / 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 Name Last Name
Date of Birth

Month Day Year
Date
Home Phone #

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work

Occupation Employer
Phone Numbers

Business Phone Number Cell Phone Number
Social Security #
Mother's Full Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Home Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work

Occupation Employer
Phone Numbers

Business Phone Number Cell Phone Number
Social Security #
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 Code Phone Number
Group # and ID #

Group Number ID Number
This Dental Insurance is provided through:

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

Area Code Phone Number
Group # and ID #

Group Number ID Number
This Dental Insurance is provided through:

Name of policy holder Relationship to Child
Dental and Medical History:
Check the box if your child has ever had any of the following medical conditions or problems: *

Heart Murmur ADD/ADHDHyperactive Heart problems (any kind) Diabetes Hypertension Any stays in hospital Convuisions/Epilepsy Gagger Hemophilia Bleeding Problems Hearing Impairment Any Operations Glaucoma Migraines Cancer Diabetes HIV + /AIDS Rheumatic Fever Hepatitis Latex Allergy None of these
DOES YOUR CHILD NEED TO BE PREMEDICATED BEFORE DENTAL TREATMENT?

Yes No
Are there any other medical conditions or problems relating to your child? If Yes, Explain.

No
Is your child currently under the care of a physician? If so, please answer the following:

Name of Physician The 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 Physician The approx. date of last visit: Their Phone Number
Have there been any injuries to the face, mouth or teeth?

Yes No
Has your child had tongue thrust or speech therapy?

Yes No
Does your child have any speech problems?

Yes No
Have you ever been informed of any missing or extra teeth?

Yes No
Does your child’s jaw ever crack or pop sound when chewing or yawning?

Yes No
Have you been told your child has TMJ (Temporomandibular Joint) problems?

Yes No
Is your child a mouth breather?

Yes No
Has your child’s jaw ever locked open?

Yes No
Has an orthodontist been consulted previously?

No
Has your child ever sucked his/her thumb or fingers?

No
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:

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Today's Date *

Month Day Year
Date
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