Pair Orthodontics Northridge 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
Date
Best Phone Number

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

NameRelationship
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
Date
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
Date
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 ORTHODONTIC 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 #
Dental Insurance is provided through:

Name of policy holderRelationship to Child
Date of Birth of the Insurance Holder

MonthDayYear
Date
DENTAL INSURANCE COMPANY #2
Name of Insurance Company
Their Phone Number

Area CodePhone Number
Group # and ID #

Group NumberID Number
Dental Insurance is provided through:

Name of policy holderRelationship to Child
Date of Birth of the Insurance Holder

MonthDayYear
Date
Dental and Medical History:
Check the box if your child has ever had any of the following medical conditions or problems:*

Heart MurmurADD/ADHDHyperactiveHeart problems (any kind)DiabetesHypertensionAny stays in hospitalConvulsions/EpilepsyGaggerHemophiliaBleeding ProblemsHearing ImpairmentAny OperationsGlaucomaMigrainesCancerHIV + /AIDSRheumatic FeverHepatitisLatex AllergyNone of theseAutism
DOES YOUR CHILD NEED TO BE PREMEDICATED BEFORE DENTAL TREATMENT?

YesNo
Are there any other medical conditions or problems relating to your child? If Yes, Explain.

NoOther
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?

YesNo
Has your child had tongue thrust or speech therapy?

YesNo
Does your child have any speech problems?

YesNo
Have you ever been informed of any missing or extra teeth?

YesNo
Does your child’s jaw ever crack or make a pop sound when chewing or yawning?

YesNo
Have you been told your child has TMJ (Temporomandibular Joint) problems?

YesNo
Is your child a mouth breather?

YesNo
Has your child’s jaw ever locked open?

YesNo
Has an orthodontist been consulted previously?

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

NoOther
WHAT DO YOU WANT ORTHODONTIC 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 office of any changes in my child’s medical status.
Sign below:

Clear
Today's Date*

MonthDayYear
Date
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