Child New Patient Form ⋆ Embrace Smile Studio

Patient Information

Patient Name (Required)*:

Gender:MaleFemale

Social Security Number:

Birth Date:

Age:

Home Address:

Phone Type:HomeCell

OK to leave message?:YesNo

E-mail:

School:

Siblings (names and ages):

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Name:

Relation to Child:MotherStep-MotherGuardianOther

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone type:HomeCell

Secondary Phone:

Phone type:HomeCell

Secondary Employer's Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

SecondaryInsurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

General Dentist:

Last Visit:

How did you hear about our practice?

Name of person referring (if applicable):

What are the main concerns you would like orthodontics to correct?

Has your child visited an orthodontist before?YesNo

If yes, when?:

Reason:

Have we treated any other family members?YesNo

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNo

Does your child have any missing or extra permanent teeth?YesNo

Has your child ever had an injury to (select all that apply):TeethMouthChin

Does your child have speech problems?YeNo

If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

Is your child currently being treated by a physician?YesNo

Reason:

Physician:

Last Visit:

Phone:

Is your child currently taking any prescription or over-the-counter medications?YesNo

If yes, please list with the dosage:

Has puberty and/or menstruation begun?YesNoNA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?YesNo

If yes, give approximate dates:

Check if your child has or has ever had any of the following:

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 child's medical status.

I hereby authorize the release of any information pertaining to my child's 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.

Submitted by:

Date:

Child New Patient Form

Patient Information

Parent / Guardian Information

Emergency Contact Information

Insurance Information

Primary Insurance

SecondaryInsurance

Dental History

Medical History

Authorization

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