to the orthodontist: te ed d bra… · to the orthodontist: we would like to welcome you and your...
TRANSCRIPT
TO THE ORTHODONTIST: We would like to welcome you and your child to our office.Our goal is to make every child’s visit pleasant and educational. We strive to teach good oral care
that will enable your child to have a beautiful smile that lasts a lifetime.
Tell Us About Your Child
Today’s Date: ____________ Nickname:__________________NAME CHILD LIKES TO BE CALLED
Child’s Name: _____________________________________LAST FIRST MI
E-mail Address: ____________________ SS#: ______________
Birthdate: _______________Age:_________ Male Female
School: ___________________________Grade: _____________
Hobbies / Sports: _____________________________________
Child’s Hm #: (_____) ________ Cell #: (_____) _____________
Child’s Home Address: ___________________________APT/CONDO #
_____________________________________________________CITY STATE ZIP
Person Responsible For Account
Who Is Accompanying Your Child Today?Name:______________________ Relation: ________________
Do you have legal custody of this child? Yes NoWho may we thank for referring you?____________________
List brothers / sisters with age: __________________________
_____________________________________________________
General Dentist: _______________________________________
Last Visit Date: ________________________________________
Parent’s Marital Status:
Mother’s Information: Step Mother Guardian
Email: ________________________________ Cell #:___________________
Name: __________________________ Birthdate: ______________Wk #: (_____) ____________Ext: ____ Hm #: (_____) __________Employer:______________________________________________How long at current job:______ Job Title: ____________________SS #: __________________________ DL #: _________________
Father’s Information: Step Father Guardian
Email: ________________________________ Cell #:___________________
Name: __________________________ Birthdate: _____________Wk #: (_____) ____________Ext: ____ Hm #:(_____) ___________Employer:______________________________________________How long at current job:______ Job Title: ____________________SS #: __________________________DL #: ___________________
Orthodontic Insurance
CONTINUED ON BACK
Primary Orthodontic InsuranceOrthodontic Coverage? Yes No
Insurance Co. Name:___________________________________
Insurance Co. Address: _________________________________
Insurance Co. Phone #: (_____) __________________________
Group # (Plan, Local, or Policy #):________________________
Policy Owner’s Name:__________________________________
Relationship to Patient: _________________________________
Policy Owner’s Birthdate: _________ID #: _________________
Policy Owner’s Employer: _______________________________
Employer’s Address: ___________________________________
Secondary Orthodontic InsuranceOrthodontic Coverage? Yes No
Insurance Co. Name:___________________________________
Insurance Co. Address: _________________________________
Insurance Co. Phone #: (_____) __________________________
Group # (Plan, Local, or Policy #):________________________
Policy Owner’s Name:__________________________________
Relationship to Patient: _________________________________
Policy Owner’s Birthdate: _________ID #: _________________
Policy Owner’s Employer: _______________________________
Employer’s Address: ___________________________________
/ /
/ /
/ // /
/ /
Single Partnered DivorcedMarried Separated Widowed
Name:______________________ Relation: ________________Billing Address: ____________________________________________________________________________________________
CITY STATE ZIP
Previous Address: __________________________________________________________________________________________
CITY STATE ZIP
Hm #: (_____) _________________DL #: __________________Employer: ____________________________________________Wk #: (_____) _________ Ext: _____ SS #: ________________
Who is responsible for making appointments?Name: _______________________________________________Wk #: (_____) _________ Ext: _____ Hm #:________________GHT
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___
________APT/CONDO #
_____________STATE ZIP
Your Child Today?Relation: __________
of this child? referring yo
with age: ___
_________________
ist: ___
Visit Date: ____________
rent’s Marital Status:
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Has your child ever had any of thefollowing medical problems?
Y N Abnormal BleedingY N ADD / ADHDY N Allergies to any DrugsY N Allergic to Latex / MetalsY N Allergic to PlasticY N Any Hospital StaysY N Any OperationsY N Artificial Bones / Joints /
ValvesY N AsthmaY N CancerY N Congenital Heart Defect
Y N Convulsions / EpilepsyY N DiabetesY N Handicaps / DisabilitiesY N Hearing ImpairmentY N Heart MurmurY N HemophiliaY N HepatitisY N HIV+ / AIDSY N Kidney / Liver ProblemsY N LupusY N Rheumatic / Scarlet FeverY N Tuberculosis (TB)
Has your child ever experienced any of the following?
Y N Clenching / Grinding Teeth
Y N Lip Sucking / Biting
Y N Mouth Breather
Y N Nail Biting
Y N Nursing Bottle Habits
Y N Speech Problems
Y N Thumb / Finger Sucking
Y N Tongue Thrust
Please discuss any medical problems that your child has had:
______________________________________________________
______________________________________________________
______________________________________________________
What are the main concerns that you would likeorthodontics to accomplish?_______________________
______________________________________________________
Has your child ever been prescribed Fosamaxor any other Bisphosphonate? Yes No
Has your child ever been evaluated or had orthodontictreatment before? Yes No
Have there been any injuries to theface, mouth, teeth or chin? Yes No
List any musical instruments played: _______________________Have adenoids or tonsils been removed? Yes NoHas your child been informed of any
missing or extra permanent teeth? Yes NoHas your child ever had any pain / tenderness in his / her
jaw joint (TMJ / TMD)? Yes NoDoes your child brush his / her teeth daily? Yes NoFloss his / her teeth daily? Yes NoChild’s Physician: _______________________________________Phone #: (_____) ______________Date of Last Visit: __________Is your child currently under the care of a physician?
Yes NoHas puberty begun? Yes NoHas menstruation begun? (Girls) Yes NoPlease describe your child’s current physical health:
Good Fair Poor
Please list all drugs that your child is currently taking: ________________________________________________________________
Please list all drugs / things that your child is allergic to: ______________________________________________________________Y N Latex Y N Metals/Nickel Y N Plastics
I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein.
Doctor’s Comments: Initials:________________ Date: ____________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
FORM #550-ORTHO-C SMILING BRACES www.informsonline.com © 2014 1-800-722-4884
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 thisoffice of any changes in my child’s medical status.
I authorize the dental staff to perform the necessary dentalservices my child may need.
__________________________________________________________Signature of parent or guardian Date
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 of infection control mandated by OSHA, the CDC and the ADA.
This office reserves the right to verify the credit status of potentialpatients and/or parents of patients prior to extending credit fortreatment fees and may, at the discretion of this office, use theservices of one or more credit reporting services.
__________________________________________________________Signature of parent or guardian Date
If this office accepts insurance, I understand that I am responsible forpayment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I herebyauthorize payment of the group insurance benefits directly to this office.
____________________________________________________________Signature of parent or guardian Date
Neighbor or Relative not living with you.
Name______________________ Phone (____) _______________Address _____________________________________________________________________________________________________CITY STATE ZIP
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