1. Tell Us About Your Child
Today's Date
Child’s Name
Nickname:
Male
Female
Child’s Birthdate:
Child's Age:
School:
Hobbies/Sports:
Child’s Home #:
Home Address:
2. Who Is Accompanying Your Child Today?
Name:
Relation:
Do you have legal custody of this child?
Yes
No
Whom may we Thank for referring you?
List brothers / sisters with age:
General Dentist:
Last Visit Date:
Parent’s Marital Status:
Single
Married
Widowed
Separated
Divorced
3. Mother’s Information:
Step Mother
Parental Guardian
Name:
Birthdate:
Wk #:
Cell / Hm#:
Employer:
How Long at Current Job:
Job Title:
SS#:
DL#:
Email address:
Father's Information:
Step Father
Parental Guardian
Name:
Birthdate:
Wk #:
Cell / Hm#:
Employer:
How Long at Current Job:
Job Title:
SS#:
DL#:
Email address:
4. Person Responsible For Account
Name:
Relation:
Billing Address:
Previous Address:
Home #:
DL #:
Employer:
Work #:
Ext#:
SS#:
Who is responsible for making appointments?
Name:
Work #:
Ext#:
Home #:
5. Primary Orthodontic Insurance
Orthodontic Coverage?:
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone
Group # (Plan, Local, or Policy #):
Policy Owner's Name:
Policy Owner’s Birthdate:
SS#:
Relationship to Patient:
ID#:
Policy Owner's Employer:
Secondary Orthodontic Insurance
Orthodontic Coverage?:
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone
Group # (Plan, Local, or Policy #):
Policy Owner's Name:
Policy Owner’s Birthdate:
SS#:
Relationship to Patient:
ID#:
Policy Owner's Employer:
6. Tell Us Your Concerns
What are your main concerns that you would like orthodontics to accomplish?
Check here to select No to all the Questions
Have you been to our office before?
Yes
No
Has your child ever had orthodontic treatment before?
Yes
No
Have there been any injuries to the face mouth, teeth, or chin?
Yes
No
List any musical instruments played:
Have adenoids or tonsils been removed?
Yes
No
Has your child been informed of any missing or extra permanent teeth?
Yes
No
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Yes
No
Does your child brush his/her teeth daily?
Yes
No
Floss his/her teeth daily?
Yes
No
Child's physician:
Phone #:
Date of Last Visit:
Is your child currently under the care of a physician?
Yes
No
Has puberty begun?
Yes
No
Please describe your child’s current physical health:
Good
Fair
Poor
Please list all drugs that your child is currently taking:
Please list all drugs that your child is allergic to:
7. Has Your Child Ever Had Any Of The
Following Medical Problem
Check here to select No to all the Questions
Yes
No
Abnormal Bleeding
Yes
No
Allergies to any Drugs
Yes
No
Allergic to Latex/Metals
Yes
No
Allergic to Plastic
Yes
No
Any Hospital Stays
Yes
No
Any Operations
Yes
No
Asthma
Yes
No
Cancer
Yes
No
Congenita Heart Defect
Yes
No
Convulsion/ Epilepsy
Yes
No
Diabetes
Yes
No
Handicaps/Disabilities
Yes
No
Hearing Impairment
Yes
No
Kidney/Liver Problems
Yes
No
Heart Murmur
Yes
No
Hemophilia
Yes
No
HIV+/AIDS
Yes
No
Hepatitis
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Tuberculosis
Please discuss any medical problems that your child has had:
8 . Does/Did Your Child Ever Have Any
Of The Following Habits
Yes
No
Clenching/ Grinding
Yes
No
Lip Sucking/
Yes
No
Mouth Breather
Yes
No
Poor Oral Hygiene
Yes
No
Nail Biting
Yes
No
Nursing Bottle Habits
Yes
No
Speech Problems
Yes
No
Thumb/Finger Sucking
Yes
No
Tongue Thrust
Neighbor or Relative not living with you.
Name
Phone
Address
I certify that my child is covered by
Insurance Co. and I assign directly to Dr. Cheng all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying co-payment and deductible that my insurance does not cover. I herby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Signature of parent or guardian
Date
Authorization
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 this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian
Date
Submit
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