Child New Patient Information

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Child Registration Form - Ortho
* required field

PATIENT INFORMATION-CHILD




Gender



Primary Phone Number:
Secondary Phone Number:





PARENT CONTACT INFORMATION

Marital Status




Cell Phone Number:
Work Number:






Cell Phone:
Work Number:



DENTIST/PHYSICIAN







How did you hear about our Practice?

WHO IS FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT?










Do you have Dental Insurance?

PATIENT PROFILE

 

Does patient follow directions well?
Does patient have a learning disability?
Does patient brush teeth conscientiously?
Is patient sensitive or self-conscious about teeth?

 

Medical History

Now or in the past, has your child had:


















 

Does your child have allergies or reactions to any of the following:









 

Does your child currently have or ever had a substance abuse problem?
Does your child have or ever have chewed or smoked Tobacco?


MEDICATIONS

Has your child ever taken Biphosphanate Drugs for Cancer, Osteoporosis or any other condition?

If yes, which one(s):

IV Cancer Drug:
Oral Cancer Drug

Prior to certain dental procedures, does your child take a Pre-Medication Antibiotic?

DENTAL HISTORY

Now or in the past has your child ever had the following:













Would your child mind wearing braces?
Has your child been under another specialist care (Periodontist, Endodontist, Oral Surgeon, etc...)?

Has any relative ever had jaw surgery to correct their bite?
Does any relative have an under bite?
How often does your child brush a day?
How often does your child floss?

 


 

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.


HIPAA ACKNOWLEDGEMENT I, the parent/guardian, acknowledge the Notice of Privacy Practice is available for me to read or print from Embrace Our World Orthodontics through their website. By initialing below, I, the parent/guardian consent to the use and disclosure of the patient protected health information to carry out treatment, payment activities, and healthcare operations.



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